1
|
Owen VS, Sinnadurai S, Morrissey J, Colaco H, Wickson P, Dyjur D, Redlich M, O'Neill B, Zygun DA, Doig CJ, Harris J, Zuege DJ, Stelfox HT, Faris PD, Fiest KM, Niven DJ. Multicentre implementation of a quality improvement initiative to reduce delirium in adult intensive care units: An interrupted time series analysis. J Crit Care 2024; 81:154524. [PMID: 38199062 DOI: 10.1016/j.jcrc.2024.154524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 01/12/2024]
Abstract
PURPOSE The ABCDEF bundle may improve delirium outcomes among intensive care unit (ICU) patients, however population-based studies are lacking. In this study we evaluated effects of a quality improvement initiative based on the ABCDEF bundle in adult ICUs in Alberta, Canada. MATERIAL AND METHODS We conducted a pre-post, registry-based clinical trial, analysed using interrupted time series methodology. Outcomes were examined via segmented linear regression using mixed effects models. The main data source was a population-based electronic health record. RESULTS 44,405 consecutive admissions (38,400 unique patients) admitted to 15 general medical/surgical and/or neurologic adult ICUs between 2014 and 2019 were included. The proportion of delirium days per ICU increased from 30.24% to 35.31% during the pre-intervention period. After intervention implementation it decreased significantly (bimonthly decrease of 0.34%, 95%CI 0.18-0.50%, p < 0.01) from 33.48% (95%CI 29.64-37.31%) in 2017 to 28.74% (95%CI 25.22-32.26%) in 2019. The proportion of sedation days using midazolam demonstrated an immediate decrease of 7.58% (95%CI 4.00-11.16%). There were no significant changes in duration of invasive ventilation, proportion of partial coma days, ICU mortality, or potential adverse events. CONCLUSIONS An ABCDEF delirium initiative was implemented on a population-basis within adult ICUs and was successful at reducing the prevalence of delirium.
Collapse
Affiliation(s)
- Victoria S Owen
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Selvi Sinnadurai
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - Jeanna Morrissey
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - Heather Colaco
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - Patty Wickson
- Health Innovation and Evidence, Provincial Clinical Excellence, Alberta Health Services, Alberta, Canada
| | - Donalda Dyjur
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - Melissa Redlich
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - Barbara O'Neill
- Cancer Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - David A Zygun
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Christopher J Doig
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jo Harris
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - Danny J Zuege
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Peter D Faris
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Analytics, Alberta Health Services, Alberta, Canada
| | - Kirsten M Fiest
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel J Niven
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| |
Collapse
|
2
|
Ceric A, Holgersson J, May TL, Skrifvars MB, Hästbacka J, Saxena M, Aneman A, Delaney A, Reade MC, Delcourt C, Jakobsen JC, Nielsen N. Effect of level of sedation on outcomes in critically ill adult patients: a systematic review of clinical trials with meta-analysis and trial sequential analysis. EClinicalMedicine 2024; 71:102569. [PMID: 38572080 PMCID: PMC10990717 DOI: 10.1016/j.eclinm.2024.102569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 04/05/2024] Open
Abstract
Background Sedation is routinely administered to critically ill patients to alleviate anxiety, discomfort, and patient-ventilator asynchrony. However, it must be balanced against risks such as delirium and prolonged intensive care stays. This study aimed to investigate the effects of different levels of sedation in critically ill adults. Methods Systematic review with meta-analysis and trial sequential analysis (TSA) of randomised clinical trials including critically ill adults admitted to the intensive care unit. CENTRAL, MEDLINE, Embase, LILACS, and Web of Science were searched from their inception to 13 June 2023. Risks of bias were assessed using the Cochrane risk of bias tool. Primary outcome was all-cause mortality. Aggregate data were synthesised with meta-analyses and TSA, and the certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. This study is registered with PROSPERO: CRD42023386960. Findings Fifteen trials randomising 4352 patients were included, of which 13 were assessed high risk of bias. Meta-analyses comparing lighter to deeper sedation showed no evidence of a difference in all-cause mortality (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.83-1.06; p = 0.28; 15 trials; moderate certainty evidence), serious adverse events (RR 0.99, CI 0.92-1.06; p = 0.80; 15 trials; moderate certainty evidence), or delirium (RR 1.01, 95% CI 0.94-1.09; p = 0.78; 11 trials; moderate certainty evidence). TSA showed that when assessing mortality, a relative risk reduction of 16% or more between the compared interventions could be rejected. Interpretation The level of sedation has not been shown to affect the risks of death, delirium, and other serious adverse events in critically ill adult patients. While TSA suggests that additional trials are unlikely to significantly change the conclusion of the meta-analyses, the certainty of evidence was moderate. This suggests a need for future high-quality studies with higher methodological rigor. Funding None.
Collapse
Affiliation(s)
- Ameldina Ceric
- Anesthesia & Intensive Care, Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden
| | - Johan Holgersson
- Lund University, Helsingborg Hospital, Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund, Sweden
| | - Teresa L. May
- Maine Medical Center, Department of Critical Care, Portland, Maine, USA
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Johanna Hästbacka
- Department of Anesthesiology and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Manoj Saxena
- Division of Critical Care, George Institute for Global Health, Australia
- St. George Hospital, South Eastern Sydney Local Health District, Sydney, Australia
| | - Anders Aneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, South Western Sydney Clinical School, University of New South Wales, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Anthony Delaney
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Michael C. Reade
- Medical School, University of Queensland, Brisbane, QLD, Australia
| | - Candice Delcourt
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit – Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Denmark
| | - Niklas Nielsen
- Lund University, Helsingborg Hospital, Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund, Sweden
| |
Collapse
|
3
|
Hernandez FLC, Ríos MVS, Bolivar YRC, Sánchez JIA. Optimizing patient outcomes: a comprehensive evaluation of protocolized sedation in intensive care settings: a systematic review and meta-analysis. Eur J Med Res 2024; 29:255. [PMID: 38659054 PMCID: PMC11044308 DOI: 10.1186/s40001-024-01839-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/10/2024] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION Amidst the routine utilization of protocolized sedation in ventilated ICU patients, existing management guidelines exhibit a lack of unanimous recommendations for its widespread adoption. This study endeavors to comprehensively assess the effectiveness and safety of protocolized sedation in critically ill ventilated patients. OBJECTIVE The primary objective of this study was to systematically review and conduct a meta-analysis of clinical trials comparing protocolized sedation with standard management in critically ill ventilated patients. Key outcomes under scrutiny include ICU and hospital mortality, ventilation days, duration of ICU stay, and incidents of self-extubation. The evaluation incorporates the Risk of Bias 2 (RoB2) tool to assess the quality of included studies. Data analysis utilizes a random-effects model for relative risk (RR) and mean differences. Subgroup analysis categorizes sedation protocols into algorithmic or daily interruption, addressing potential heterogeneity. Additionally, a GRADE evaluation is performed to ascertain the overall certainty of the evidence. RESULTS From an initial pool of 1504 records, 10 studies met the inclusion criteria. Protocolized sedation demonstrated a reduced RR for mortality (RR: 0.80, 95% CI 0.68-0.93, p < 0.01, I2 = 0%) and a decrease in ventilation days (mean difference: - 1.12, 95% CI - 2.11 to - 0.14, p = 0.03, I2 = 84%). Furthermore, there was a notable reduction in ICU stay (mean difference: - 2.24, 95% CI - 3.59 to - 0.89, p < 0.01, I2 = 81%). However, incidents of self-extubation did not exhibit a significant difference (RR: 1.20, 95% CI 0.49-2.94, p = 0.69, I2 = 35%). Subgroup analyses effectively eliminated heterogeneity (I2 = 0%), and the GRADE evaluation yielded moderate results for mortality, ventilation days, and ICU duration. CONCLUSION Protocolized sedation, whether implemented algorithmically or through daily interruption, emerges as a safe and effective approach when compared to standard management in ventilated ICU patients. The findings from this study contribute valuable insights to inform evidence-based practices in sedation management for this critical patient population.
Collapse
Affiliation(s)
| | | | | | - Jorge Iván Alvarado Sánchez
- Intensive Care Unit, Hospital Universitario Fundación Santa Fe de Bogotá, Universidad Nacional de Colombia, Bogotá, Colombia
| |
Collapse
|
4
|
Burns KEA, Rochwerg B, Seely AJE. Ventilator Weaning and Extubation. Crit Care Clin 2024; 40:391-408. [PMID: 38432702 DOI: 10.1016/j.ccc.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Increasing evidence supports specific approaches to liberate patients from invasive ventilation including the use of liberation protocols, inspiratory assistance during spontaneous breathing trials (SBTs), early extubation of patients with chronic obstructive pulmonary disease to noninvasive ventilation, and prophylactic use of noninvasive support strategies after extubation. Additional research is needed to elucidate the best criteria to identify patients who are ready to undergo an SBT and to inform optimal screening frequency, the best SBT technique and duration, extubation assessments, and extubation decision-making. Additional clarity is also needed regarding the optimal timing to measure and report extubation success.
Collapse
Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine and Division of Critical Care, Unity Health Toronto, St. Michaels Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Hamilton Health Sciences, Juravinski Hospital, Hamilton, Ontario, Canada; Department of Critical Care, Hamilton Health Sciences, Juravinski Hospital, Hamilton, Ontario, Canada. https://twitter.com/Bram_Rochwerg
| | - Andrew J E Seely
- Department of Critical Care, Ottawa Hospital, Ottawa, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
5
|
Quigley N, Binnie A, Baig N, Opgenorth D, Senaratne J, Sligl WI, Zuege DJ, Rewa O, Bagshaw SM, Tsang J, Lau VI. Modelling the potential increase in eligible participants in clinical trials with inclusion of community intensive care unit patients in Alberta, Canada: a decision tree analysis. Can J Anaesth 2024; 71:390-399. [PMID: 38129358 DOI: 10.1007/s12630-023-02669-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 09/09/2023] [Accepted: 09/11/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE Critical care research in Canada is conducted primarily in academically affiliated intensive care units (ICUs) with established research infrastructure. Efforts are made to engage community hospital ICUs in research, although the impacts of their inclusion in clinical research have never been explicitly quantified. We therefore sought to determine the number of additional eligible patients that could be recruited into critical care trials and the change in time to study completion if community ICUs were included in clinical research. METHODS We conducted a decision tree analysis using 2018 Alberta Health Services data. Patient demographics and clinical characteristics for all ICU patients were compared against eligibility criteria from ten landmark, randomized, multicentre critical care trials. Individual patients from academic and community ICUs were assessed for eligibility in each of the ten studies, and decision tree analysis models were built based on prior inclusion and exclusion criteria from those trials. RESULTS The number of potentially eligible patients for the ten trials ranged from 2,082 to 10,157. Potentially eligible participants from community ICUs accounted for 40.0% of total potentially eligible participants. The recruitment of community ICU patients in trials would have increased potential enrolment by an average of 64.0%. The inclusion of community ICU patients was predicted to decrease time to trial completion by a mean of 14 months (43% reduction). CONCLUSION Inclusion of community ICU patients in critical care research trials has the potential to substantially increase enrolment and decrease time to trial completion.
Collapse
Affiliation(s)
- Nicholas Quigley
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada.
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 8440 112 St, Edmonton, AB, T6G 2B7, Canada.
| | - Alexandra Binnie
- Department of Critical Care, William Osler Health System, Brampton, ON, Canada
| | - Nadia Baig
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Dawn Opgenorth
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Janek Senaratne
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Wendy I Sligl
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Danny J Zuege
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Oleksa Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Jennifer Tsang
- Division of Critical Care Medicine, Niagara Health, St. Catharines, ON, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| |
Collapse
|
6
|
Guillamet CV, Kollef MH. Is Zero Ventilator-Associated Pneumonia Achievable? Updated Practical Approaches to Ventilator-Associated Pneumonia Prevention. Infect Dis Clin North Am 2024; 38:65-86. [PMID: 38040518 DOI: 10.1016/j.idc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
Ventilator-associated pneumonia (VAP) remains a significant clinical entity with reported incidence rates of 7% to 15%. Given the considerable adverse consequences associated with this infection, VAP prevention became a core measure required in most US hospitals. Many institutions took pride in implementing effective VAP prevention bundles that combined at least head of bed elevation, hand hygiene, chlorhexidine oral care, and subglottic drainage. Spontaneous breathing and awakening trials have also consistently been shown to shorten the duration of mechanical ventilation and secondarily reduce the occurrence of VAP.
Collapse
Affiliation(s)
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA.
| |
Collapse
|
7
|
Zhong J, Martins DS, Piper HG. Standardizing vitamin D supplementation to minimize deficiency in children with intestinal failure. Nutr Clin Pract 2024; 39:177-183. [PMID: 38030590 DOI: 10.1002/ncp.11094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/17/2023] [Accepted: 10/28/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Vitamin D deficiency is present in 40%-70% of children with intestinal failure (IF), yet there are no published guidelines for repleting and maintaining vitamin D levels in this population. The purpose of this study is to evaluate the efficacy of a standardized vitamin D algorithm in reducing the incidence of deficiency. METHODS A retrospective chart review was performed in children with IF who had at least one serum vitamin D (25-hydroxyvitamin D3 ) measurement. Vitamin D levels were compared prealgorithm (2014-2016) and during active-algorithm use (2018-2020). Vitamin D levels were classified as severe deficiency (<12.5 nmol per L), mild deficiency (12.5-39 nmol/L), insufficiency (40-74 nmol/L), optimal (75-224 nmol/L), or toxicity (>225 nmol/L). Descriptive and comparative statistics were calculated using a linear mixed-effects model, with P < 0.05 considered significant. RESULTS Twenty-eight children with IF were enrolled, which included 157 vitamin D measurements (58 in the prealgorithm group and 98 in the active-algorithm group). Algorithm compliance was 4% in the prealgorithm group and 61% in the active-algorithm group. Active-algorithm patients had improved vitamin D levels in all categories compared with those of prealgorithm patients (mild deficiency: 8% vs 9%; insufficiency: 41% vs 72%; optimal: 50% vs 19%). Algorithm use was found to have a statistically significant effect on serum vitamin D levels (β = 21.58; 95% confidence interval, 14.11-29.05; P < 0.005). CONCLUSIONS Children with IF are at high risk for vitamin D deficiency. Use of a standardized vitamin D supplementation algorithm was associated with increased serum vitamin D levels.
Collapse
Affiliation(s)
- Jade Zhong
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Debby S Martins
- Complex Feeding and Nutrition Service, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Hannah G Piper
- Division of Pediatric Surgery, University of British Columbia, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| |
Collapse
|
8
|
Bracht H, Meiser A, Wallenborn J, Guenther U, Kogelmann KM, Faltlhauser A, Schwarzkopf K, Soukup J, Becher T, Kellner P, Knafelj R, Sackey P, Bellgardt M. ICU- and ventilator-free days with isoflurane or propofol as a primary sedative - A post- hoc analysis of a randomized controlled trial. J Crit Care 2023; 78:154350. [PMID: 37327507 DOI: 10.1016/j.jcrc.2023.154350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 05/19/2023] [Accepted: 05/26/2023] [Indexed: 06/18/2023]
Abstract
PURPOSE To compare ICU-free (ICU-FD) and ventilator-free days (VFD) in the 30 days after randomization in patients that received isoflurane or propofol without receiving the other sedative. MATERIALS AND METHODS A recent randomized controlled trial (RCT) compared inhaled isoflurane via the Sedaconda® anaesthetic conserving device (ACD) with intravenous propofol for up to 54 h (Meiser et al. 2021). After end of study treatment, continued sedation was locally determined. Patients were eligible for this post-hoc analysis only if they had available 30-day follow-up data and never converted to the other drug in the 30 days from randomization. Data on ventilator use, ICU stay, concomitant sedative use, renal replacement therapy (RRT) and mortality were collected. RESULTS Sixty-nine of 150 patients randomized to isoflurane and 109 of 151 patients randomized to propofol were eligible. After adjusting for potential confounders, the isoflurane group had more ICU-FD than the propofol group (17.3 vs 13.8 days, p = 0.028). VFD for the isoflurane and propofol groups were 19.8 and 18.5 respectively (p = 0.454). Other sedatives were used more frequently (p < 0.0001) and RRT started in a greater proportion of patients in the propofol group (p = 0.011). CONCLUSIONS Isoflurane via the ACD was not associated with more VFD but with more ICU-FD and less concomitant sedative use.
Collapse
Affiliation(s)
- Hendrik Bracht
- University Hospital Bielefeld Bethel, Campus Bielefeld-Bethel, Department of Anesthesiology, Intensive Care, Emergency and Transfusion Medicine and Pain Therapy, Bielefeld, Germany.
| | - Andreas Meiser
- University Hospital Homburg/Saar, Department of Anaesthesiology, Homburg, Germany
| | - Jan Wallenborn
- HELIOS Klinikum Aue, Department of Anaesthesiology, AUE, Germany
| | - Ulf Guenther
- University Clinic of Anaesthesiology, Klinikum Oldenburg, Oldenburg Research Network Emergency- and Intensive Care Medicine (OFNI), Faculty VI - Medicine and Health Sciences, Carl v. Ossietzky University Oldenburg, Oldenburg, Germany
| | | | - Andreas Faltlhauser
- Central Emergency Care Unit and Admission HDU, Wels General Hospital, Wels, Austria
| | - Konrad Schwarzkopf
- Department of Anesthesia and Intensive Care, Klinikum Saarbruecken, Saarbruecken, Germany
| | - Jens Soukup
- Department of Anaesthesiology, Intensive Care Medicine and Palliative Care Medicine, Carl-Thiem-Hospital, Cottbus, Germany
| | - Tobias Becher
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Patrick Kellner
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Luebeck, Germany
| | - Rihard Knafelj
- University Medical Center Ljubljana, Klinični oddelek za interno Intenzivno Medicine, KOIIM, Ljubljana, Slovenia
| | - Peter Sackey
- Department of Physiology and Pharmacology, Unit of Anaesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Martin Bellgardt
- Department of Anaesthesiology and intensive Care Medicine, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Germany
| |
Collapse
|
9
|
Alkhateeb T, Semler MW, Girard TD, Ely EW, Stollings JL. Comparison of SAT and SBT Conduct During the ABC Trial and PILOT Trial. J Intensive Care Med 2023:8850666231213337. [PMID: 37981753 DOI: 10.1177/08850666231213337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
BACKGROUND Implementation of the "B" element-both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs)-of the ABCDEF bundle improves the outcomes for mechanically ventilated patients. In 2021, the Pragmatic Investigation of optimal Oxygen Targets (PILOT) trial investigating optimal oxygenation targets in patients on mechanical ventilation was completed. OBJECTIVES To compare SAT and SBT conduct between a randomized controlled trial and current clinical care. METHODS The 2008 Awakening and Breathing Controlled (ABC) Trial (2003-2006) randomized mechanically ventilated patients to paired SATs and SBTs versus sedation per usual care plus SBTs. The PILOT trial (2018-2021) enrolled patients years later where SAT + SBT conduct was observed. We compared SAT and SBT conduct in ABC's interventional group (SAT + SBT; n = 167, 1140 patient days) to that in PILOT (n = 2083, 8355 patient days). RESULTS Spontaneous awakening trial safety screens were done in all 1140 ABC patient-days on sedation and/or analgesia and in 3889 of 4228 (92%) in PILOT. Spontaneous awakening trial safety screens were passed in 939 of 1140 (82%) instances in ABC versus only 1897 of 3889 (49%) in PILOT. Interestingly, SAT was performed in ≥95% of passed SAT safety screens in both trials and was passed in 837 of 895 (94%) in ABC versus 1145 of 1867 (61%) in PILOT. SBT safety screens were performed in all 983 ABC instances and 8031 of 8370 (96%) in PILOT. SBT safety screens were passed in 647 of 983 (66%) in ABC versus 4475 of 8031 (56%) in PILOT. Spontaneous breathing trial was performed in ≥93% of passed SBT safety screens in both trials and was passed in 319 of 603 (53%) in ABC versus 3337 of 4454 (75%) in PILOT. CONCLUSION This study compared SAT/SBT conduction in an ideal setting to real-world practice, 13 years later. Performance of SAT/SBT safety screens, SATs, and SBTs between a definitive clinical trial (ABC) as compared to current clinical care (PILOT) remained high.
Collapse
Affiliation(s)
- Tuqa Alkhateeb
- The Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy D Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - E Wesley Ely
- The Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center Tennessee Valley Healthcare System, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joanna L Stollings
- The Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
10
|
Torre A, Cisneros-Garza LE, Castillo-Barradas M, Navarro-Alvarez N, Sandoval-Salas R, González-Huezo MS, Pérez-Hernández JL, Méndez-Guerrero O, Ruiz-Manríquez JA, Trejo-Estrada R, Chavez-Tapia NC, Solís-Gasca LC, Moctezuma-Velázquez C, Aguirre-Valádez J, Flores-Calderón J, Higuera-de-la-Tijera F, García-Juárez I, Canedo-Castillo NA, Malé-Velázquez R, Montalvo-Gordon I, Vilatobá M, Márquez-Guillén E, Córdova-Gallardo J, Flores-García NC, Miranda-Zazueta G, Martínez-Saldívar BI, Páez-Zayas VM, Muñoz-Espinosa LE, Solís-Galindo FA. Consensus document on acute-on-chronic liver failure (ACLF) established by the Mexican Association of Hepatology. Ann Hepatol 2023; 28:101140. [PMID: 37482299 DOI: 10.1016/j.aohep.2023.101140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/26/2023] [Accepted: 05/31/2023] [Indexed: 07/25/2023]
Abstract
Acute-on chronic liver failure (ACLF) has been an intensively debated topic mainly due to the lack of a unified definition and diagnostic criteria. The growing number of publications describing the mechanisms of ACLF development, the progression of the disease, outcomes and treatment has contributed to a better understanding of the disease, however, it has also sparked the debate about this condition. As an attempt to provide medical professionals with a more uniform definition that could be applied to our population, the first Mexican consensus was performed by a panel of experts in the area of hepatology in Mexico. We used the most relevant and impactful publications along with the clinical and research experience of the consensus participants. The consensus was led by 4 coordinators who provided the most relevant bibliography by doing an exhaustive search on the topic. The entire bibliography was made available to the members of the consensus for consultation at any time during the process and six working groups were formed to develop the following sections: 1.- Generalities, definitions, and criteria, 2.- Pathophysiology of cirrhosis, 3.- Genetics in ACLF, 4.- Clinical manifestations, 5.- Liver transplantation in ACLF, 6.- Other treatments.
Collapse
Affiliation(s)
- Aldo Torre
- Metabolic Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| | - Laura Esthela Cisneros-Garza
- Gastroenterology and Hepatology Department, Hospital Christus Muguerza Alta Especialidad, Monterrey, Nuevo León, Mexico
| | | | - Nalu Navarro-Alvarez
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | - Osvely Méndez-Guerrero
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | - Luis Carlos Solís-Gasca
- Gastroenterology Department, Hospital General de Zona #12 Benito Juárez del Instituto Mexicano del Seguro Social, Mérida, Yucatán, Mexico
| | - Carlos Moctezuma-Velázquez
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Department of Medicine - Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | | | - Judith Flores-Calderón
- Pediatrics Department, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Mexico City, Mexico
| | | | - Ignacio García-Juárez
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Iaarah Montalvo-Gordon
- Clinic of Gastrointestinal and Hepatic Specialties, Hospital Faro del Mayab, Mérida, Yucatán, Mexico
| | - Mario Vilatobá
- Transplant Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ernesto Márquez-Guillén
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Hospital Ángeles del Pedregal, Mexico City, Mexico
| | - Jacqueline Córdova-Gallardo
- Hepatology Department - General Surgery Service, Hospital General Dr. Manuel Gea González, Mexico City, Mexico
| | - Nayeli Cointa Flores-García
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Godolfino Miranda-Zazueta
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Linda Elsa Muñoz-Espinosa
- Universidad Autónoma de Nuevo León. Liver Unit, Department of Internal Medicine, University Hospital 'Dr. José E. González', Monterrey, Nuevo León, Mexico
| | - Francisco Alfonso Solís-Galindo
- Gastroenterology Department, Unidad Médica de Alta Especialidad # 71 Instituto Mexicano del Seguro Social, Torreón, Coahuila, Mexico
| |
Collapse
|
11
|
Pruskowski KA, Feth M, Hong L, Wiggins AR. Pharmacologic Management of Pain, Agitation, and Delirium in Burn Patients. Surg Clin North Am 2023; 103:495-504. [PMID: 37149385 DOI: 10.1016/j.suc.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
The majority of hospitalized burn patients experience pain, agitation, and delirium. The development of each one of these conditions can also lead to, or worsen, the others. Providers, therefore, need to thoroughly assess the underlying issue to determine the most effective treatment. Multimodal pharmacologic regimens are often used in conjunction with non-pharmacologic strategies to manage pain, agitation, and delirium. This review focuses on the pharmacologic management of these complicated patients in a critical-care setting.
Collapse
Affiliation(s)
- Kaitlin A Pruskowski
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA; Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Maximilian Feth
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA; Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Federal Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Linda Hong
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA
| | - Amanda R Wiggins
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA
| |
Collapse
|
12
|
Pham T, Heunks L, Bellani G, Madotto F, Aragao I, Beduneau G, Goligher EC, Grasselli G, Laake JH, Mancebo J, Peñuelas O, Piquilloud L, Pesenti A, Wunsch H, van Haren F, Brochard L, Laffey JG, Acharya SP, Amin P, Arabi Y, Aragao I, Bauer P, Beduneau G, Beitler J, Berkius J, Bugedo G, Camporota L, Cerny V, Cho YJ, Clarkson K, Estenssoro E, Goligher E, Grasselli G, Gritsan A, Hashemian SM, Hermans G, Heunks LM, Jovanovic B, Kurahashi K, Laake JH, Matamis D, Moerer O, Molnar Z, Ozyilmaz E, Panka B, Papali A, Peñuelas Ó, Perbet S, Piquilloud L, Qiu H, Razek AA, Rittayamai N, Roldan R, Serpa Neto A, Szuldrzynski K, Talmor D, Tomescu D, Van Haren F, Villagomez A, Zeggwagh AA, Abe T, Aboshady A, Acampo-de Jong M, Acharya S, Adderley J, Adiguzel N, Agrawal VK, Aguilar G, Aguirre G, Aguirre-Bermeo H, Ahlström B, Akbas T, Akker M, Al Sadeh G, Alamri S, Algaba A, Ali M, Aliberti A, Allegue JM, Alvarez D, Amador J, Andersen FH, Ansari S, Apichatbutr Y, Apostolopoulou O, Arabi Y, Arellano D, Arica M, Arikan H, Arinaga K, Arnal JM, Asano K, Asín-Corrochano M, Avalos Cabrera JM, Avila Fuentes S, Aydemir S, Aygencel G, Azevedo L, Bacakoglu F, Badie J, Baedorf Kassis E, Bai G, Balaraj G, Ballico B, Banner-Goodspeed V, Banwarie P, Barbieri R, Baronia A, Barrett J, Barrot L, Barrueco-Francioni JE, Barry J, Bauer P, Bawangade H, Beavis S, Beck E, Beehre N, Belenguer Muncharaz A, Bellani G, Belliato M, Bellissima A, Beltramelli R, Ben Souissi A, Benitez-Cano A, Benlamin M, Benslama A, Bento L, Benvenuti D, Berkius J, Bernabe L, Bersten A, Berta G, Bertini P, Bertram-Ralph E, Besbes M, Bettini LR, Beuret P, Bewley J, Bezzi M, Bhakhtiani L, Bhandary R, Bhowmick K, Bihari S, Bissett B, Blythe D, Bocher S, Boedjawan N, Bojanowski CM, Boni E, Boraso S, Borelli M, Borello S, Borislavova M, Bosma KJ, Bottiroli M, Boyd O, Bozbay S, Briva A, Brochard L, Bruel C, Bruni A, Buehner U, Bugedo G, Bulpa P, Burt K, Buscot M, Buttera S, Cabrera J, Caccese R, Caironi P, Canchos Gutierrez I, Canedo N, Cani A, Cappellini I, Carazo J, Cardonnet LP, Carpio D, Carriedo D, Carrillo R, Carvalho J, Caser E, Castelli A, Castillo Quintero M, Castro H, Catorze N, Cengiz M, Cereijo E, Ceunen H, Chaintoutis C, Chang Y, Chaparro G, Chapman C, Chau S, Chavez CE, Chelazzi C, Chelly J, Chemouni F, Chen K, Chena A, Chiarandini P, Chilton P, Chiumello D, Cho YJ, Chou-Lie Y, Chudeau N, Cinel I, Cinnella G, Clark M, Clark T, Clarkson K, Clementi S, Coaguila L, Codecido AJ, Collins A, Colombo R, Conde J, Consales G, Cook T, Coppadoro A, Cornejo R, Cortegiani A, Coxo C, Cracchiolo AN, Crespo Ramirez M, Crova P, Cruz J, Cubattoli L, Çukurova Z, Curto F, Czempik P, D'Andrea R, da Silva Ramos F, Dangers L, Danguy des Déserts M, Danin PE, Dantas F, Daubin C, Dawei W, de Haro C, de Jesus Montelongo F, De Mendoza D, de Pablo R, De Pascale G, De Rosa S, Decavèle M, Declercq PL, Deicas A, del Carmen Campos Moreno M, Dellamonica J, Delmas B, Demirkiran O, Demirkiran H, Dendane T, di Mussi R, Diakaki C, Diaz A, Diaz W, Dikmen Y, Dimoula A, Doble P, Doha N, Domingos G, Dres M, Dries D, Duggal A, Duke G, Dunts P, Dybwik K, Dykyy M, Eckert P, Efe S, Elatrous S, Elay G, Elmaryul AS, Elsaadany M, Elsayed H, Elsayed S, Emery M, Ena S, Eng K, Englert JA, Erdogan E, Ergin Ozcan P, Eroglu E, Escobar M, Esen F, Esen Tekeli A, Esquivel A, Esquivel Gallegos H, Ezzouine H, Facchini A, Faheem M, Fanelli V, Farina MF, Fartoukh M, Fehrle L, Feng F, Feng Y, Fernandez I, Fernandez B, Fernandez-Rodriguez ML, Ferrando C, Ferreira da Silva MJ, Ferreruela M, Ferrier J, Flamm Zamorano MJ, Flood L, Floris L, Fluckiger M, Forteza C, Fortunato A, Frans E, Frattari A, Fredes S, Frenzel T, Fumagalli R, Furche MA, Fusari M, Fysh E, Galeas-Lopez JL, Galerneau LM, Garcia A, Garcia MF, Garcia E, Garcia Olivares P, Garlicki J, Garnero A, Garofalo E, Gautam P, Gazenkampf A, Gelinotte S, Gelormini D, Ghrenassia E, Giacomucci A, Giannoni R, Gigante A, Glober N, Gnesin P, Gollo Y, Gomaa D, Gomero Paredes R, Gomes R, Gomez RA, Gomez O, Gomez A, Gondim L, Gonzalez M, Gonzalez I, Gonzalez-Castro A, Gordillo Romero O, Gordo F, Gouin P, Graf Santos J, Grainne R, Grando M, Granov Grabovica S, Grasselli G, Grasso S, Grasso R, Grimmer L, Grissom C, Gritsan A, Gu Q, Guan XD, Guarracino F, Guasch N, Guatteri L, Gueret R, Guérin C, Guerot E, Guitard PG, Gül F, Gumus A, Gurjar M, Gutierrez P, Hachimi A, Hadzibegovic A, Hagan S, Hammel C, Han Song J, Hanlon G, Hashemian SM, Heines S, Henriksson J, Herbrecht JE, Heredia Orbegoso GO, Hermans G, Hermon A, Hernandez R, Hernandez C, Herrera L, Herrera-Gutierrez M, Heunks L, Hidalgo J, Hill D, Holmquist D, Homez M, Hongtao X, Hormis A, Horner D, Hornos MC, Hou M, House S, Housni B, Hugill K, Humphreys S, Humbert L, Hunter S, Hwa Young L, Iezzi N, Ilutovich S, Inal V, Innes R, Ioannides P, Iotti GA, Ippolito M, Irie H, Iriyama H, Itagaki T, Izura J, Izza S, Jabeen R, Jamaati H, Jamadarkhana S, Jamoussi A, Jankowski M, Jaramillo LA, Jeon K, Jeong Lee S, Jeswani D, Jha S, Jiang L, Jing C, Jochmans S, Johnstad BA, Jongmin L, Joret A, Jovanovic B, Junhasavasdikul D, Jurado MT, Kam E, Kamohara H, Kane C, Kara I, Karakurt S, Karnjanarachata C, Kataoka J, Katayama S, Kaushik S, Kelebek Girgin N, Kerr K, Kerslake I, Khairnar P, Khalid A, Khan A, Khanna AK, Khorasanee R, Kienhorst D, Kirakli C, Knafelj R, Kol MK, Kongpolprom N, Kopitko C, Korkmaz Ekren P, Kubisz-Pudelko A, Kulcsar Z, Kumasawa J, Kurahashi K, Kuriyama A, Kutchak F, Laake JH, Labarca E, Labat F, Laborda C, Laca Barrera MA, Lagache L, Landaverde Lopez A, Lanspa M, Lascari V, Le Meur M, Lee SH, Lee YJ, Lee J, Lee WY, Lee J, Legernaes T, Leiner T, Lemiale V, Leonor T, Lepper PM, Li D, Li H, Li O, Lima AR, Lind D, Litton E, Liu N, Liu L, Liu J, Llitjos JF, Llorente B, Lopez R, Lopez CE, Lopez Nava C, Lovazzano P, Lu M, Lucchese F, Lugano M, Lugo Goytia G, Luo H, Lynch C, Macheda S, Madrigal Robles VH, Maggiore SM, Magret Iglesias M, Malaga P, Mallapura Maheswarappa H, Malpartida G, Malyarchikov A, Mansson H, Manzano A, Marey I, Marin N, Marin MDC, Markman E, Martin F, Martin A, Martin Dal Gesso C, Martinez F, Martínez-Fidalgo C, Martin-Loeches I, Mas A, Masaaki S, Maseda E, Massa E, Mattsson A, Maugeri J, McCredie V, McCullough J, McGuinness S, McKown A, Medve L, Mei C, Mellado Artigas R, Mendes V, Mervat MKE, Michaux I, Mikhaeil M, Milagros O, Milet I, Millan MT, Minwei Z, Mirabella L, Mishra S, Mistraletti G, Mochizuki K, Moerer O, Moghal A, Mojoli F, Molin A, Molnar Z, Montiel R, Montini L, Monza G, Mora Aznar M, Morakul S, Morales M, Moreno Torres D, Morocho Tutillo DR, Motherway C, Mouhssine D, Mouloudi E, Muñoz T, Munoz de Cabo C, Mustafa M, Muthuchellappan R, Muthukrishnan M, Muttini S, Nagata I, Nahar D, Nakanishi M, Nakayama I, Namendys-Silva SA, Nanchal R, Nandakumar S, Nasi A, Nasir K, Navalesi P, Naz Aslam T, Nga Phan T, Nichol A, Niiyama S, Nikolakopoulou S, Nikolic E, Nitta K, Noc M, Nonas S, Nseir S, Nur Soyturk A, Obata Y, Oeckler R, Oguchi M, Ohshimo S, Oikonomou M, Ojados A, Oliveira MT, Oliveira Filho W, Oliveri C, Olmos A, Omura K, Orlandi MC, Orsenigo F, Ortiz-Ruiz De Gordoa L, Ota K, Ovalle Olmos R, Öveges N, Oziemski P, Ozkan Kuscu O, Özyilmaz E, Pachas Alvarado F, Pagella G, Palaniswamy V, Palazon Sanchez EL, Palmese S, Pan G, Pan W, Panka B, Papanikolaou M, Papavasilopoulou T, Parekh A, Parke R, Parrilla FJ, Parrilla D, Pasha T, Pasin L, Patão L, Patel M, Patel G, Pati BK, Patil J, Pattnaik S, Paul D, Pavesi M, Pavlotsky VA, Paz G, Paz E, Pecci E, Pellegrini C, Peña Padilla AG, Perchiazzi G, Pereira T, Pereira V, Perez M, Perez Calvo C, Perez Cheng M, Perez Maita R, Pérez-Araos R, Perez-Teran P, Perez-Torres D, Perkins G, Persona P, Petnak T, Petrova M, Pham T, Philippart F, Picetti E, Pierucci E, Piervincenzi E, Pinciroli R, Pintado MC, Piquilloud L, Piraino T, Piras S, Piras C, Pirompanich P, Pisani L, Platas E, Plotnikow G, Porras W, Porta V, Portilla M, Portugal J, Povoa P, Prat G, Pratto R, Preda G, Prieto I, Prol-Silva E, Pugh R, Qi Y, Qian C, Qin T, Qiu H, Qu H, Quintana T, Quispe Sierra R, Quispe Soto R, Rabbani R, Rabee M, Rabie A, Rahe Pereira MA, Rai A, Raj Ashok S, Rajab M, Ramdhani N, Ramey E, Ranieri M, Rathod D, Ray B, Redwanul Huq SM, Regli A, Reina R, Resano Sarmiento N, Reynaud F, Rialp G, Ricart P, Rice T, Richardson A, Rieder M, Rinket M, Rios F, Rios F, Risso Vazquez A, Rittayamai N, Riva I, Rivette M, Roca O, Roche-Campo F, Rodriguez C, Rodriguez G, Rodriguez Gonzalez D, Rodriguez Tucto XY, Rogers A, Romano ME, Rørtveit L, Rose A, Roux D, Rouze A, Rubatto Birri PN, Ruilan W, Ruiz Robledo A, Ruiz-Aguilar AL, Sadahiro T, Saez I, Sagardia J, Saha R, Saha R, Saiphoklang N, Saito S, Salem M, Sales G, Salgado P, Samavedam S, Sami Mebazaa M, Samuelsson L, San Juan Roman N, Sanchez P, Sanchez-Ballesteros J, Sandoval Y, Sani E, Santos M, Santos C, Sanui M, Saravanabavan L, Sari S, Sarkany A, Sauneuf B, Savioli M, Sazak H, Scano R, Schneider F, Schortgen F, Schultz MJ, Schwarz GL, Seçkin Yücesoy F, Seely A, Seiler F, Seker Tekdos Y, Seok Chan K, Serano L, Serednicki W, Serpa Neto A, Setten M, Shah A, Shah B, Shang Y, Shanmugasundaram P, Shapovalov K, Shebl E, Shiga T, Shime N, Shin P, Short J, Shuhua C, Siddiqui S, Silesky Jimenez JI, Silva D, Silva Sales B, Simons K, Sjøbø BÅ, Slessor D, Smiechowicz J, Smischney N, Smith P, Smith T, Smith M, Snape S, Snyman L, Soetens F, Sook Hong K, Sosa Medellin MÁ, Soto G, Souloy X, Sousa E, Sovatzis S, Sozutek D, Spadaro S, Spagnoli M, Spångfors M, Spittle N, Spivey M, Stapleton A, Stefanovic B, Stephenson L, Stevenson E, Strand K, Strano MT, Straus S, Sun C, Sun R, Sundaram V, SunPark T, Surlemont E, Sutherasan Y, Szabo Z, Szuldrzynski K, Tainter C, Takaba A, Tallott M, Tamasato T, Tang Z, Tangsujaritvijit V, Taniguchi L, Taniguchi D, Tarantino F, Teerapuncharoen K, Temprano S, Terragni P, Terzi N, Thakur A, Theerawit P, Thille AW, Thomas M, Thungtitigul P, Thyrault M, Tilouch N, Timenetsky K, Tirapu J, Todeschini M, Tomas R, Tomaszewski C, Tonetti T, Tonnelier A, Trinder J, Trongtrakul K, Truwit J, Tsuei B, Tulaimat A, Turan S, Turkoglu M, Tyagi S, Ubeda A, Vagginelli F, Valenti MF, Vallverdu I, Van Axel A, van den Hul I, van der Hoeven H, Van Der Meer N, Van Haren F, Vanhoof M, Vargas-Ordoñez M, Vaschetto R, Vascotto E, Vatsik M, Vaz A, Vazquez-Sanchez A, Ventura S, Vermeijden JW, Vidal A, Vieira J, Vilela Costa Pinto B, Villagomez A, Villagra A, Villegas Succar C, Vinorum OG, Vitale G, Vj R, Vochin A, Voiriot G, Volta CA, von Seth M, Wajdi M, Walsh D, Wang S, Wardi G, Ween-Velken NC, Wei BL, Weller D, Welsh D, Welters I, Wert M, Whiteley S, Wilby E, Williams E, Williams K, Wilson A, Wojtas J, Won Huh J, Wrathall D, Wright C, Wu JF, Xi G, Xing ZJ, Xu H, Yamamoto K, Yan J, Yáñez J, Yang X, Yates E, Yazicioglu Mocin O, Ye Z, Yildirim F, Yoshida N, Yoshido HHL, Young Lee B, Yu R, Yu G, Yu T, Yuan B, Yuangtrakul N, Yumoto T, Yun X, Zakalik G, Zaki A, Zalba-Etayo B, Zambon M, Zang B, Zani G, Zarka J, Zerbi SM, Zerman A, Zetterquist H, Zhang J, Zhang H, Zhang W, Zhang G, Zhang W, Zhao H, Zheng J, Zhu B, Zumaran R. Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study. THE LANCET. RESPIRATORY MEDICINE 2023; 11:465-476. [PMID: 36693401 DOI: 10.1016/s2213-2600(22)00449-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/07/2022] [Accepted: 11/10/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. METHODS WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. FINDINGS Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. INTERPRETATION In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. FUNDING European Society of Intensive Care Medicine, European Respiratory Society.
Collapse
Affiliation(s)
- Tài Pham
- Service de Médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de Recherche CARMAS, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France; Université Paris-Saclay, UVSQ, Université Paris-Sud, Inserm U1018, Equipe d'Epidémiologie Respiratoire Intégrative, CESP, 94807, Villejuif, France
| | - Leo Heunks
- Department of Intensive Care Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Fabiana Madotto
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Aragao
- Department of Intensive Care Medicine, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Gaëtan Beduneau
- Normandie University, UNIROUEN, UR 3830, CHU Rouen, Department of Medical Intensive Care, F-76000 Rouen, France
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, Division of Respirology, Toronto General Hospital Research Institute University Health Network, Toronto, Canada
| | - Giacomo Grasselli
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Jon Henrik Laake
- Department of Anaesthesiology and Department of Research and Development, Division of Critical Care and Emergencies, Oslo University Hospital, Oslo, Norway
| | - Jordi Mancebo
- Department of Intensive Care Medicine, Hospital Universitari Sant Pau, Barcelona, Spain
| | - Oscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red, CIBER de Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Antonio Pesenti
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Frank van Haren
- College of Health and Medicine, Australian National University, Canberra, ACT, Australia; Intensive Care Unit, St George Hospital, Sydney, NSW, Australia
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, Clinical Sciences Institute, Galway University Hospitals, Galway, Ireland; School of Medicine, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Ren X, Ai Y, Zhang L, Zhao C, Li L, Ma X. Sedation and analgesia requirements during venovenous extracorporeal membrane oxygenation in acute respiratory distress syndrome patients. Perfusion 2023; 38:313-319. [PMID: 34743615 DOI: 10.1177/02676591211052160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The purpose of this study is to describe sedation and analgesia management, and identify the factors associated with increased demand for medication in acute respiratory distress syndrome (ARDS) patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO). METHODS This retrospective, single-center study included consecutive adult ARDS patients who received VV-ECMO for at least 24 hours from January 2018 to December 2020 in a comprehensive intensive care unit. The electronic medical records were retrospectively reviewed to collect data. RESULTS Forty-two adult patients meeting the inclusion criteria were included in the study. Midazolam, sufentanil, and remifentanil were main sedatives and analgesics used in the patient population. The morphine equivalents, representative of the demand for opioids, was 512.9 (IQR, 294.5, 798.2) mg/day. The midazolam equivalents, representative of benzodiazepine requirement, was 279.6 (IQR, 208.8, 384.5) mg/day. The levels of serum creatinine, total bilirubin, lactic acid, SOFA score, and APACHE Ⅱ score at cannulation were found to be associated with opiate or benzodiazepine requirements. Multiple linear regression analysis revealed a linear correlation between midazolam equivalents and morphine equivalents (p < 0.001). In addition, there was a negative linear correlation between Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) score and midazolam equivalents (p = 0.024). CONCLUSIONS The sedation and analgesia requirements of ARDS patients receiving VV-ECMO often increase simultaneously. More large-scale studies are needed to confirm the risk factors for increased sedation and analgesia needs in patients supported on VV-ECMO.
Collapse
Affiliation(s)
- Xingshu Ren
- Department of Critical Care Medicine, Xiangya Hospital of Central South University, Changsha, China
| | - Yuhang Ai
- Department of Critical Care Medicine, Xiangya Hospital of Central South University, Changsha, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital of Central South University, Changsha, China
| | - Chunguang Zhao
- Department of Critical Care Medicine, Xiangya Hospital of Central South University, Changsha, China
| | - Li Li
- Department of Critical Care Medicine, Xiangya Hospital of Central South University, Changsha, China
| | - Xinhua Ma
- Department of Critical Care Medicine, Xiangya Hospital of Central South University, Changsha, China
| |
Collapse
|
14
|
Moscote-Salazar LR, Florez-Perdomo WA, Janjua T. Sedation Vacation in Neurocritical Care: A Proposal Algorithm. INDIAN JOURNAL OF NEUROTRAUMA 2023. [DOI: 10.1055/s-0043-1762599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
AbstractDaily sedation interruption or sedation vacation is a strategy for neurological evaluation, respiratory mechanics, cardiac stability, and eventual weaning to extubation. However, its application has safety aspects such as pulmonary, cardiac, and neurological complications.A protocol-driven sedation vacation in the medical intensive care helps with the reduction in the intensive care length of stay and increase in ventilator-free days.1,2 The same approach can be used in neurointensive care with alterations based upon the neurocritical care progression.
Collapse
Affiliation(s)
| | - William A. Florez-Perdomo
- Department of Critical Care Medicine, Physician Regional Medical Center, Naples, Florida, United States
| | - Tariq Janjua
- Colombian Clinical Research Group in Neurocritical Care, Bogota, Colombia
| |
Collapse
|
15
|
Ceric A, May TL, Lybeck A, Cronberg T, Seder DB, Riker RR, Hassager C, Kjaergaard J, Haxhija Z, Friberg H, Dankiewicz J, Nielsen N. Cardiac Arrest Treatment Center Differences in Sedation and Analgesia Dosing During Targeted Temperature Management. Neurocrit Care 2023; 38:16-25. [PMID: 35896768 PMCID: PMC9935704 DOI: 10.1007/s12028-022-01564-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 06/20/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sedation and analgesia are recommended during targeted temperature management (TTM) after cardiac arrest, but there are few data to provide guidance on dosing to bedside clinicians. We evaluated differences in patient-level sedation and analgesia dosing in an international multicenter TTM trial to better characterize current practice and clinically important outcomes. METHODS A total 950 patients in the international TTM trial were randomly assigned to a TTM of 33 °C or 36 °C after resuscitation from cardiac arrest in 36 intensive care units. We recorded cumulative doses of sedative and analgesic drugs at 12, 24, and 48 h and normalized to midazolam and fentanyl equivalents. We compared number of medications used, dosing, and titration among centers by using multivariable models, including common severity of illness factors. We also compared dosing with time to awakening, incidence of clinical seizures, and survival. RESULTS A total of 614 patients at 18 centers were analyzed. Propofol (70%) and fentanyl (51%) were most frequently used. The average dosages of midazolam and fentanyl equivalents were 0.13 (0.07, 0.22) mg/kg/h and 1.16 (0.49, 1.81) µg/kg/h, respectively. There were significant differences in number of medications (p < 0.001), average dosages (p < 0.001), and titration at all time points between centers (p < 0.001), and the outcomes of patients in these centers were associated with all parameters described in the multivariate analysis, except for a difference in the titration of sedatives between 12 and 24 h (p = 0.40). There were associations between higher dosing at 48 h (p = 0.003, odds ratio [OR] 1.75) and increased titration of analgesics between 24 and 48 h (p = 0.005, OR 4.89) with awakening after 5 days, increased titration of sedatives between 24 and 48 h with awakening after 5 days (p < 0.001, OR > 100), and increased titration of sedatives between 24 and 48 h with a higher incidence of clinical seizures in the multivariate analysis (p = 0.04, OR 240). There were also significant associations between decreased titration of analgesics and survival at 6 months in the multivariate analysis (p = 0.048). CONCLUSIONS There is significant variation in choice of drug, dosing, and titration when providing sedation and analgesics between centers. Sedation and analgesia dosing and titration were associated with delayed awakening, incidence of clinical seizures, and survival, but the causal relation of these findings cannot be proven.
Collapse
Affiliation(s)
- Ameldina Ceric
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Svartbrödragränden 3, 251 87, Helsingborg, Sweden.
| | - Teresa L May
- Department of Critical Care, Maine Medical Center, Portland, ME, USA
| | - Anna Lybeck
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Tobias Cronberg
- Division of Neurology, Department of Clinical Sciences, Skane University Hospital, Lund University, Lund, Sweden
| | - David B Seder
- Department of Critical Care, Maine Medical Center, Portland, ME, USA
| | - Richard R Riker
- Department of Critical Care, Maine Medical Center, Portland, ME, USA
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Zana Haxhija
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Svartbrödragränden 3, 251 87, Helsingborg, Sweden
| | - Hans Friberg
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Malmö, Sweden
| | - Josef Dankiewicz
- Division of Cardiology, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Svartbrödragränden 3, 251 87, Helsingborg, Sweden
| |
Collapse
|
16
|
Rawson TM, Antcliffe DB, Wilson RC, Abdolrasouli A, Moore LSP. Management of Bacterial and Fungal Infections in the ICU: Diagnosis, Treatment, and Prevention Recommendations. Infect Drug Resist 2023; 16:2709-2726. [PMID: 37168515 PMCID: PMC10166098 DOI: 10.2147/idr.s390946] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/22/2023] [Indexed: 05/13/2023] Open
Abstract
Bacterial and fungal infections are common issues for patients in the intensive care unit (ICU). Large, multinational point prevalence surveys have identified that up to 50% of ICU patients have a diagnosis of bacterial or fungal infection at any one time. Infection in the ICU is associated with its own challenges. Causative organisms often harbour intrinsic and acquired mechanisms of drug-resistance, making empiric and targeted antimicrobial selection challenging. Infection in the ICU is associated with worse clinical outcomes for patients. We review the epidemiology of bacterial and fungal infection in the ICU. We discuss risk factors for acquisition, approaches to diagnosis and management, and common strategies for the prevention of infection.
Collapse
Affiliation(s)
- Timothy M Rawson
- Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Hospital, London, UK
- Centre for Antimicrobial Optimisation, Imperial College London, Imperial College London, London, UK
- David Price Evan’s Group in Infectious Diseases and Global Health, Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- Correspondence: Timothy M Rawson, Health Protection Research Unit in Healthcare Associated Infections & Antimicrobial Resistance, Hammersmith Hospital, Du Cane Road, London, W12 0NN, United Kingdom, Email
| | - David B Antcliffe
- Centre for Antimicrobial Optimisation, Imperial College London, Imperial College London, London, UK
- Division Anaesthesia, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Richard C Wilson
- Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Hospital, London, UK
- Centre for Antimicrobial Optimisation, Imperial College London, Imperial College London, London, UK
- David Price Evan’s Group in Infectious Diseases and Global Health, Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | | | - Luke S P Moore
- Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Hospital, London, UK
- Chelsea & Westminster NHS Foundation Trust, London, UK
- North West London Pathology, Imperial College Healthcare NHS Trust, London, UK
| |
Collapse
|
17
|
What Is Known about Midazolam? A Bibliometric Approach of the Literature. Healthcare (Basel) 2022; 11:healthcare11010096. [PMID: 36611556 PMCID: PMC9819597 DOI: 10.3390/healthcare11010096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/24/2022] [Accepted: 11/25/2022] [Indexed: 12/30/2022] Open
Abstract
Midazolam is a drug with actions towards the central nervous system producing sedative and anticonvulsants effects, used for sedation and seizures treatments. A better understanding about its effects in the different scenarios presented in the literature could be helpful to gather information regarding its clinical indications, pharmacological interactions, and adverse events. From this perspective, the aim of this study was to analyze the global research about midazolam mapping, specifically the knowledge of the 100 most-cited papers about this research field. For this, a search was executed on the Web of Science-Core Collection database using bibliometric methodological tools. The search strategy retrieved 34,799 articles. A total of 170 articles were evaluated, with 70 articles being excluded for not meeting the inclusion criteria. The 100 most-cited articles rendered 42,480 citations on WoS-CC, ranging from 253 to 1744. Non-systematic review was the most published study type, mainly from North America, during the period of 1992 to 2002. The most frequent keywords were midazolam and pharmacokinetics. Regarding the authors, Thummel and Kunze were the ones with the greatest number of papers included. Our findings showed the global research trends about midazolam, mainly related to its different effects and uses throughout the time.
Collapse
|
18
|
Zhang Y, Yang G, Wei J, Chen F, Zhang MZ, Mao S. Prospective comparison of acupuncture with sham acupuncture to determine impact on sedation and analgesia in mechanically ventilated critically ill patients (PASSION study): protocol for a randomised controlled trial. BMJ Open 2022; 12:e059741. [PMID: 36041767 PMCID: PMC9438044 DOI: 10.1136/bmjopen-2021-059741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Sedation and analgesia are recommended to be employed in the intensive care unit (ICU) to enhance patient comfort and safety, facilitate mechanical ventilation and reduce oxygen demands. However, the increasing evidence demonstrates that excessive sedation and analgesia might prolong mechanical ventilation and increase costs and mortality. Acupuncture is known to be able to attenuate pain, anxiety and agitation symptoms while avoiding excessive sedation and analgesia caused by drugs. Therefore, we present a protocol to investigate whether acupuncture, used for sedation and analgesia, can reduce the duration of mechanical ventilation, save medical resources and reduce the mortality of critically ill patients receiving mechanical ventilation. METHODS AND ANALYSIS Prospective, randomised controlled trial is conducted on 180 adult medical/surgical ICU patients with mechanical ventilation needing sedation at 3 ICUs between 03 November 2021 and 16 August 2023. Patients will be treated with analgesia and sedation to achieve desired target sedation levels (Richmond Agitation Sedation Score of -2 to 1). Enrolled patients will be randomly assigned in a ratio of 1:1:1 to receive deep needle insertion with combined manual and alternating-mode electrical stimulation on acupoints (AC group), superficial needle insertion without manual stimulation and electrical stimulation on non-acupoints (SAC group), or no acupuncture intervention (NAC group). The primary outcome is the duration of mechanical ventilation from randomisation until patients are free of mechanical ventilation (including non-invasive) without reinstitution for the following 48 hours. Secondary endpoints include the dose of administered sedatives and analgesic at comparable sedation levels throughout the study, ICU length of stay, hospital length of stay. Additional outcomes include the prevalence and days of delirium in ICU, mortality in ICU and within 28 days after randomisation, and the number of ventilator free days in 28 days. ETHICS AND DISSEMINATION This trial was approved by the ethics committee at Guangdong Provincial Hospital of Chinese Medicine. We will publish the study results. TRIAL REGISTRATION NUMBER ChiCTR2100052650.
Collapse
Affiliation(s)
- Yuzhuo Zhang
- Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Guang Yang
- Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jinyi Wei
- Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fangliang Chen
- Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Min-Zhou Zhang
- Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shuai Mao
- Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| |
Collapse
|
19
|
Dianti J, Fard S, Wong J, Chan TCY, Del Sorbo L, Fan E, Amato MBP, Granton J, Burry L, Reid WD, Zhang B, Ratano D, Keshavjee S, Slutsky AS, Brochard LJ, Ferguson ND, Goligher EC. Strategies for lung- and diaphragm-protective ventilation in acute hypoxemic respiratory failure: a physiological trial. Crit Care 2022; 26:259. [PMID: 36038890 PMCID: PMC9422941 DOI: 10.1186/s13054-022-04123-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/08/2022] [Indexed: 12/02/2022] Open
Abstract
Background Insufficient or excessive respiratory effort during acute hypoxemic respiratory failure (AHRF) increases the risk of lung and diaphragm injury. We sought to establish whether respiratory effort can be optimized to achieve lung- and diaphragm-protective (LDP) targets (esophageal pressure swing − 3 to − 8 cm H2O; dynamic transpulmonary driving pressure ≤ 15 cm H2O) during AHRF. Methods In patients with early AHRF, spontaneous breathing was initiated as soon as passive ventilation was not deemed mandatory. Inspiratory pressure, sedation, positive end-expiratory pressure (PEEP), and sweep gas flow (in patients receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO)) were systematically titrated to achieve LDP targets. Additionally, partial neuromuscular blockade (pNMBA) was administered in patients with refractory excessive respiratory effort. Results Of 30 patients enrolled, most had severe AHRF; 16 required VV-ECMO. Respiratory effort was absent in all at enrolment. After initiating spontaneous breathing, most exhibited high respiratory effort and only 6/30 met LDP targets. After titrating ventilation, sedation, and sweep gas flow, LDP targets were achieved in 20/30. LDP targets were more likely to be achieved in patients on VV-ECMO (median OR 10, 95% CrI 2, 81) and at the PEEP level associated with improved dynamic compliance (median OR 33, 95% CrI 5, 898). Administration of pNMBA to patients with refractory excessive effort was well-tolerated and effectively achieved LDP targets. Conclusion Respiratory effort is frequently absent under deep sedation but becomes excessive when spontaneous breathing is permitted in patients with moderate or severe AHRF. Systematically titrating ventilation and sedation can optimize respiratory effort for lung and diaphragm protection in most patients. VV-ECMO can greatly facilitate the delivery of a LDP strategy. Trial registration: This trial was registered in Clinicaltrials.gov in August 2018 (NCT03612583). Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04123-9.
Collapse
|
20
|
Rogers AD, Amaral A, Cartotto R, El Khatib A, Fowler R, Logsetty S, Malic C, Mason S, Nickerson D, Papp A, Rasmussen J, Wallace D. Choosing wisely in burn care. Burns 2022; 48:1097-1103. [PMID: 34563420 DOI: 10.1016/j.burns.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/15/2021] [Accepted: 09/13/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The Choosing Wisely Campaign was launched in 2012 and has been applied to a broad spectrum of disciplines in almost thirty countries, with the objective of reducing unnecessary or potentially harmful investigations and procedures, thus limiting costs and improving outcomes. In Canada, patients with burn injuries are usually initially assessed by primary care and emergency providers, while plastic or general surgeons provide ongoing management. We sought to develop a series of Choosing Wisely statements for burn care to guide these practitioners and inform suitable, cost-effective investigations and treatment choices. METHODS The Choosing Wisely Canada list for Burns was developed by members of the Canadian Special Interest Group of the American Burn Association. Eleven recommendations were generated from an initial list of 29 statements using a modified Delphi process and SurveyMonkey™. RESULTS Recommendations included statements on avoidance of prophylactic antibiotics, restriction of blood products, use of adjunctive analgesic medications, monitoring and titration of opioid analgesics, and minimizing 'routine' bloodwork, microbiology or radiological investigations. CONCLUSIONS The Choosing Wisely recommendations aim to encourage greater discussion between those involved in burn care, other health care professionals, and their patients, with a view to reduce the cost and adverse effects associated with unnecessary therapeutic and diagnostic procedures, while still maintaining high standards of evidence-based burn care.
Collapse
Affiliation(s)
- A D Rogers
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - A Amaral
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - R Cartotto
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - A El Khatib
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - R Fowler
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - S Logsetty
- Manitoba Firefighters Burn Unit, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - C Malic
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - S Mason
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - D Nickerson
- Calgary Firefighters' Burn Treatment Centre, Foothills Medical Centre, Department of Surgery, University of Calgary, Alberta, Canada
| | - A Papp
- BC Professional Firefighters' Burn Unit, Vancouver General Hospital, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - J Rasmussen
- Queen Elizabeth II Health Sciences Centre Burn Unit, Dalhousie University, Halifax, Nova Scotia, Canada
| | - D Wallace
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
21
|
Gitti N, Renzi S, Marchesi M, Bertoni M, Lobo FA, Rasulo FA, Goffi A, Pozzi M, Piva S. Seeking the Light in Intensive Care Unit Sedation: The Optimal Sedation Strategy for Critically Ill Patients. Front Med (Lausanne) 2022; 9:901343. [PMID: 35814788 PMCID: PMC9265444 DOI: 10.3389/fmed.2022.901343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/20/2022] [Indexed: 12/12/2022] Open
Abstract
The clinical approach to sedation in critically ill patients has changed dramatically over the last two decades, moving to a regimen of light or non-sedation associated with adequate analgesia to guarantee the patient’s comfort, active interaction with the environment and family, and early mobilization and assessment of delirium. Although deep sedation (DS) may still be necessary for certain clinical scenarios, it should be limited to strict indications, such as mechanically ventilated patients with Acute Respiratory Distress Syndrome (ARDS), status epilepticus, intracranial hypertension, or those requiring target temperature management. DS, if not indicated, is associated with prolonged duration of mechanical ventilation and ICU stay, and increased mortality. Therefore, continuous monitoring of the level of sedation, especially when associated with the raw EEG data, is important to avoid unnecessary oversedation and to convert a DS strategy to light sedation as soon as possible. The approach to the management of critically ill patients is multidimensional, so targeted sedation should be considered in the context of the ABCDEF bundle, a holistic patient approach. Sedation may interfere with early mobilization and family engagement and may have an impact on delirium assessment and risk. If adequately applied, the ABCDEF bundle allows for a patient-centered, multidimensional, and multi-professional ICU care model to be achieved, with a positive impact on appropriate sedation and patient comfort, along with other important determinants of long-term patient outcomes.
Collapse
Affiliation(s)
- Nicola Gitti
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Stefania Renzi
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Mattia Marchesi
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Francisco A. Lobo
- Institute of Anesthesiology, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Frank A. Rasulo
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Matteo Pozzi
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Simone Piva
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- *Correspondence: Simone Piva,
| |
Collapse
|
22
|
Stephens RJ, Evans EM, Pajor MJ, Pappal RD, Egan HM, Wei M, Hayes H, Morris JA, Becker N, Roberts BW, Kollef MH, Mohr NM, Fuller BM. A dual-center cohort study on the association between early deep sedation and clinical outcomes in mechanically ventilated patients during the COVID-19 pandemic: The COVID-SED study. Crit Care 2022; 26:179. [PMID: 35705989 PMCID: PMC9198202 DOI: 10.1186/s13054-022-04042-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/25/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Mechanically ventilated patients have experienced greater periods of prolonged deep sedation during the coronavirus disease (COVID-19) pandemic. Multiple studies from the pre-COVID era demonstrate that early deep sedation is associated with worse outcome. Despite this, there is a lack of data on sedation depth and its impact on outcome for mechanically ventilated patients during the COVID-19 pandemic. We sought to characterize the emergency department (ED) and intensive care unit (ICU) sedation practices during the COVID-19 pandemic, and to determine if early deep sedation was associated with worse clinical outcomes. STUDY DESIGN AND METHODS Dual-center, retrospective cohort study conducted over 6 months (March-August, 2020), involving consecutive, mechanically ventilated adults. All sedation-related data during the first 48 h were collected. Deep sedation was defined as Richmond Agitation-Sedation Scale of - 3 to - 5 or Riker Sedation-Agitation Scale of 1-3. To examine impact of early sedation depth on hospital mortality (primary outcome), we used a multivariable logistic regression model. Secondary outcomes included ventilator-, ICU-, and hospital-free days. RESULTS 391 patients were studied, and 283 (72.4%) experienced early deep sedation. Deeply sedated patients received higher cumulative doses of fentanyl, propofol, midazolam, and ketamine when compared to light sedation. Deep sedation patients experienced fewer ventilator-, ICU-, and hospital-free days, and greater mortality (30.4% versus 11.1%) when compared to light sedation (p < 0.01 for all). After adjusting for confounders, early deep sedation remained significantly associated with higher mortality (adjusted OR 3.44; 95% CI 1.65-7.17; p < 0.01). These results were stable in the subgroup of patients with COVID-19. CONCLUSIONS The management of sedation for mechanically ventilated patients in the ICU has changed during the COVID pandemic. Early deep sedation is common and independently associated with worse clinical outcomes. A protocol-driven approach to sedation, targeting light sedation as early as possible, should continue to remain the default approach.
Collapse
Affiliation(s)
- Robert J. Stephens
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, Campus Box 8054, St. Louis, MO 63110 USA
| | - Erin M. Evans
- Division of Critical Care, Departments of Emergency Medicine and Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242 USA
| | - Michael J. Pajor
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, Campus Box 8054, St. Louis, MO 63110 USA
| | - Ryan D. Pappal
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
| | - Haley M. Egan
- Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Max Wei
- Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Hunter Hayes
- Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Jason A. Morris
- Department of Emergency Medicine, Harvard-Affiliated Emergency Medicine Residency, Mass General Brigham, Boston, MA 02115 USA
| | - Nicholas Becker
- Department of Emergency Medicine, Mount Sinai Morningside/West, New York, NY 10025 USA
| | - Brian W. Roberts
- Department of Emergency Medicine, Cooper University Hospital, One Cooper Plaza, Camden, NJ K152 USA
| | - Marin H. Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
| | - Nicholas M. Mohr
- Division of Critical Care, Departments of Emergency Medicine and Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242 USA
| | - Brian M. Fuller
- Division of Critical Care, Departments of Anesthesiology and Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
| |
Collapse
|
23
|
Brown C, Marotta PJ, Riker RR, Eldridge AD, Fraser GL, May TL. Prospective Validation of Sedation Scale Scores That Identify Light Sedation: A Pilot Study. Am J Crit Care 2022; 31:202-208. [PMID: 35466351 DOI: 10.4037/ajcc2022437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Intensive care unit (ICU) sedation guidelines recommend targeting a light sedation level, but light sedation has no accepted definition, and inconsistent levels have been proposed. OBJECTIVE To determine Sedation-Agitation Scale and Richmond Agitation-Sedation Scale scores that best describe patients' ability to follow voice commands. METHODS This prospective, observational pilot study enrolled a convenience sample of ICU patients receiving mechanical ventilation. Pairs of trained investigators evaluated scores on the Sedation-Agitation Scale and Richmond Agitation-Sedation Scale and ability to follow commands before and up to 2 hours after sedation lightening in a blind, independent, simultaneous fashion. Positive predictive values (PPVs) and likelihood ratios (LRs) of Sedation-Agitation Scale and Richmond Agitation-Sedation Scale scores associated with light sedation (ability to follow at least 3 commands) were calculated. RESULTS Ninety-six assessments (50 before and 46 after lightening of sedation) were performed in medical ICU patients. Scores best associated with ability to follow at least 3 commands were Sedation-Agitation Scale score of 4 (PPV, 0.88; 95% CI, 0.70-0.98; LR, 14.0) and Richmond Agitation-Sedation Scale score of -1 (PPV, 0.81; 95% CI, 0.61-0.93; LR, 10.7), superior to previously recommended thresholds of Sedation-Agitation Scale score of 3 (PPV, 0.62; 95% CI, 0.48-0.75; LR, 3.1) and Richmond Agitation-Sedation Scale score of -3 (PPV, 0.52; 95% CI, 0.39-0.64; LR, 2.0). CONCLUSIONS The level of sedation most associated with the ability to follow commands appears higher than previously recommended. Further study is needed regarding the effects of sedation level on ICU patients' ability to follow commands and assessment of delirium, pain, and patient preferences.
Collapse
Affiliation(s)
- Caitlin Brown
- Caitlin Brown was a critical care pharmacy resident at Maine Medical Center, Portland, Maine, when the study was done and is currently a neurocritical care and emergency medicine pharmacist at Mayo Clinic, Rochester, Minnesota
| | - Pasquale Joseph Marotta
- Pasquale Joseph Marotta was a medical student at University of New England College of Osteopathic Medicine during the study and is now a senior internal medicine resident at Maine Medical Center
| | - Richard R. Riker
- Richard R. Riker is director of medical critical care, Department of Critical Care Services, Maine Medical Center
| | - Ashley D. Eldridge
- Ashley D. Eldridge is a clinical research coordinator and a bedside nurse in the Special Care Unit at Maine Medical Center
| | - Gilles L. Fraser
- Gilles L. Fraser was the critical care pharmacist at Maine Medical Center at the time of the study, and is now manager of Smiling Gil Farm
| | - Teresa L. May
- Teresa L. May is a neurointensivist and medical intensivist, Department of Critical Care Services, Maine Medical Center
| |
Collapse
|
24
|
Kho ME, Rewa OG, Boyd JG, Choong K, Stewart GCH, Herridge MS. Outcomes of critically ill COVID-19 survivors and caregivers: a case study-centred narrative review. Can J Anaesth 2022; 69:630-643. [PMID: 35102495 PMCID: PMC8802985 DOI: 10.1007/s12630-022-02194-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 11/10/2021] [Accepted: 11/22/2021] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Critical illness is a transformative experience for both patients and their family members. For COVID-19 patients admitted to the intensive care unit (ICU), survival may be the start of a long road to recovery. Our knowledge of the post-ICU long-term sequelae of acute respiratory distress syndrome (ARDS) and severe acute respiratory syndrome (SARS) may inform our understanding and management of the long-term effects of COVID-19. SOURCE We identified international and Canadian epidemiologic data on ICU admissions for COVID-19, COVID-19 pathophysiology, emerging ICU practice patterns, early reports of long-term outcomes, and federal support programs for survivors and their families. Centred around an illustrating case study, we applied relevant literature from ARDS and SARS to contextualize knowledge within emerging COVID-19 research and extrapolate findings to future long-term outcomes. PRINCIPAL FINDINGS COVID-19 is a multisystem disease with unknown long-term morbidity and mortality. Its pathophysiology is distinct and unique from ARDS, SARS, and critical illness. Nevertheless, based on initial reports of critical care management for COVID-19 and the varied injurious supportive practices employed in the ICU, patients and families are at risk for post-intensive care syndrome. The distinct incremental risk of COVID-19 multiple organ dysfunction is unknown. The risk of mood disorders in family members may be further exacerbated by imposed isolation and stigma. CONCLUSION Emerging literature on COVID-19 outcomes suggests some similarities with those of ARDS/SARS and prolonged mechanical ventilation. The pathophysiology of COVID-19 is presented here in the context of early outcome data and to inform an agenda for longitudinal research for patients and families.
Collapse
Affiliation(s)
- Michelle E Kho
- School of Rehabilitation Science, Faculty of Health Science, McMaster University, Hamilton, ON, Canada.
- School of Rehabilitation Science, Institute of Applied Health Sciences, McMaster University, Room 403, 1400 Main Street West, Hamilton, ON, L8S 1C7, Canada.
| | - Oleksa G Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - J Gordon Boyd
- Centre for Neuroscience Studies, Kingston Health Sciences Centre, and Department of Critical Care, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Karen Choong
- Department of Pediatrics and the Department of Health Research Methods, Evidence, and Impact McMaster University, Hamilton, ON, Canada
| | | | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto and University Health Network, Toronto General Hospital, Toronto, ON, Canada
| |
Collapse
|
25
|
The Feasibility of Implementing Targeted SEDation in Mechanically Ventilated Emergency Department Patients: The ED-SED Pilot Trial. Crit Care Med 2022; 50:1224-1235. [PMID: 35404327 PMCID: PMC9288529 DOI: 10.1097/ccm.0000000000005558] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Deep sedation in the emergency department (ED) is common, increases deep sedation in the ICU, and is negatively associated with outcome. Limiting ED deep sedation may, therefore, be a high-yield intervention to improve outcome. However, the feasibility of conducting an adequately powered ED-based clinical sedation trial is unknown. Our objectives were to assess trial feasibility in terms of: 1) recruitment, 2) protocol implementation and practice change, and 3) safety. Patient-centered clinical outcomes were assessed to better plan for a future large-scale clinical trial. DESIGN Pragmatic, multicenter (n = 3), prospective before-after pilot and feasibility trial. SETTING The ED and ICUs at three medical centers. PATIENTS Consecutive, adult mechanically ventilation ED patients. INTERVENTIONS An educational initiative aimed at reliable ED sedation depth documentation and reducing the proportion of deeply sedated patients (primary outcome). MEASUREMENTS AND MAIN RESULTS Sedation-related data in the ED and the first 48 ICU hours were recorded. Deep sedation was defined as a Richmond Agitation-Sedation Scale of -3 to -5 or a Sedation-Agitation Scale of 1-3. One thousand three hundred fifty-six patients were screened; 415 comprised the final population. Lighter ED sedation was achieved in the intervention group, and the proportion of deeply sedated patients was reduced from 60.2% to 38.8% (p < 0.01). There were no concerning trends in adverse events (i.e., inadvertent extubation, device removal, and awareness with paralysis). Mortality was 10.0% in the intervention group and 20.4% in the preintervention group (p < 0.01). Compared with preintervention, the intervention group experienced more ventilator-free days [22.0 (9.0) vs 19.9 (10.6)] and ICU-free days [20.8 (8.7) vs 18.1 (10.4)], p < 0.05 for both. CONCLUSIONS This pilot trial confirmed the feasibility of targeting the ED in order to improve sedation practices and reduce deep sedation. These findings justify an appropriately powered clinical trial regarding ED-based sedation to improve clinical outcomes.
Collapse
|
26
|
Naloxegol to Prevent Constipation in ICU Adults Receiving Opioids: A Randomized Double-Blind Placebo-Controlled Pilot Trial. Crit Care Res Pract 2022; 2022:7541378. [PMID: 35356796 PMCID: PMC8958087 DOI: 10.1155/2022/7541378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/01/2022] [Indexed: 11/29/2022] Open
Abstract
Background Constipation is frequent in critically ill adults receiving opioids. Naloxegol (N), a peripherally acting mu-receptor antagonist (PAMORA), may reduce constipation. The objective of this trial was to evaluate the efficacy and safety of N to prevent constipation in ICU adults receiving opioids. Methods and Patients. In this single-center, double-blind, randomized trial, adults admitted to a medical ICU receiving IV opioids (≥100 mcg fentanyl/day), and not having any of 17 exclusion criteria, were randomized to N (25 mg) or placebo (P) daily randomized to receive N (25mg) or placebo (P) and docusate 100 mg twice daily until ICU discharge, 10 days, or diarrhea (≥3 spontaneous bowel movement (SBM)/24 hours) or a serious adverse event related to study medication. A 4-step laxative protocol was initiated when there was no SBM ≥3 days. Results Only 318 (20.6%) of the 1542 screened adults during the 1/17–10/19 enrolment period met all inclusion criteria. Of these, only 19/381 (4.9%) met all eligibility criteria. After 7 consent refusals, 12 patients were randomized. The study was stopped early due to enrolment futility. The N (n = 6) and P (n = 6) groups were similar. The time to first SBM (N 41.4 ± 31.7 vs. P 32.5 ± 25.4 hours, P = 0.56) was similar. The maximal daily abdominal pressure was significantly lower in the N group (N 10 ± 4 vs. P 13 ± 5, P = 0.002). The median (IQR) daily SOFA scores were higher in N (N 7 (4, 8) vs. P 4 (3, 5), P < 0.001). Laxative protocol use was similar (N 83.3% vs. P 66.6%; P = 0.51). Diarrhea prevalence was high but similar (N 66.6% vs. P 66.6%; P = 1.0). No patient experienced opioid withdrawal. Conclusions Important recruitment challenges exist for ICU trials evaluating the use of PAMORAs for constipation prevention. Despite being underpowered, our results suggest time to first SBM with naloxegol, if different than P, may be small. The effect of naloxegol on abdominal pressure, SOFA, and the interaction between the two requires further research.
Collapse
|
27
|
Chen TJ, Traynor V, Wang AY, Shih CY, Tu MC, Chuang CH, Chiu HY, Chang HC(R. Comparative Effectiveness of Non-Pharmacological Interventions for Preventing Delirium in Critically Ill Adults: A Systematic Review and Network Meta-Analysis. Int J Nurs Stud 2022; 131:104239. [DOI: 10.1016/j.ijnurstu.2022.104239] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 03/10/2022] [Accepted: 03/22/2022] [Indexed: 11/16/2022]
|
28
|
Seo Y, Lee HJ, Ha EJ, Ha TS. 2021 KSCCM clinical practice guidelines for pain, agitation, delirium, immobility, and sleep disturbance in the intensive care unit. Acute Crit Care 2022; 37:1-25. [PMID: 35279975 PMCID: PMC8918705 DOI: 10.4266/acc.2022.00094] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/22/2022] [Indexed: 01/12/2023] Open
Abstract
We revised and expanded the “2010 Guideline for the Use of Sedatives and Analgesics in the Adult Intensive Care Unit (ICU).” We revised the 2010 Guideline based mainly on the 2018 “Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) in Adult Patients in the ICU,” which was an updated 2013 pain, agitation, and delirium guideline with the inclusion of two additional topics (rehabilitation/mobility and sleep). Since it was not possible to hold face-to-face meetings of panels due to the coronavirus disease 2019 (COVID-19) pandemic, all discussions took place via virtual conference platforms and e-mail with the participation of all panelists. All authors drafted the recommendations, and all panelists discussed and revised the recommendations several times. The quality of evidence for each recommendation was classified as high (level A), moderate (level B), or low/very low (level C), and all panelists voted on the quality level of each recommendation. The participating panelists had no conflicts of interest on related topics. The development of this guideline was independent of any industry funding. The Pain, Agitation/Sedation, Delirium, Immobility (rehabilitation/mobilization), and Sleep Disturbance panels issued 42 recommendations (level A, 6; level B, 18; and level C, 18). The 2021 clinical practice guideline provides up-to-date information on how to prevent and manage pain, agitation/sedation, delirium, immobility, and sleep disturbance in adult ICU patients. We believe that these guidelines can provide an integrated method for clinicians to manage PADIS in adult ICU patients.
Collapse
|
29
|
Balas MC, Tan A, Pun BT, Ely EW, Carson SS, Mion L, Barnes-Daly MA, Vasilevskis EE. Effects of a National Quality Improvement Collaborative on ABCDEF Bundle Implementation. Am J Crit Care 2022; 31:54-64. [PMID: 34972842 PMCID: PMC9972543 DOI: 10.4037/ajcc2022768] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The ABCDEF bundle (Assess, prevent, and manage pain and Delirium; Both spontaneous awakening and breathing trials; Choice of analgesia/sedation; Early mobility; and Family engagement) improves intensive care unit outcomes, but adoption into practice is poor. OBJECTIVE To assess the effect of quality improvement collaborative participation on ABCDEF bundle performance. METHODS This interrupted time series analysis included 20 months of bundle performance data from 15 226 adults admitted to 68 US intensive care units. Segmented regression models were used to quantify complete and individual bundle element performance changes over time and compare performance patterns before (6 months) and after (14 months) collaborative initiation. RESULTS Complete bundle performance rates were very low at baseline (<4%) but increased to 12% by the end. Complete bundle performance increased by 2 percentage points (SE, 0.9; P = .06) immediately after collaborative initiation. Each subsequent month was associated with an increase of 0.6 percentage points (SE, 0.2; P = .04). Performance rates increased significantly immediately after initiation for pain assessment (7.6% [SE, 2.0%], P = .002), sedation assessment (9.1% [SE, 3.7%], P = .02), and family engagement (7.8% [SE, 3%], P = .02) and then increased monthly at the same speed as the trend in the baseline period. Performance rates were lowest for spontaneous awakening/breathing trials and early mobility. CONCLUSIONS Quality improvement collaborative participation resulted in clinically meaningful, but small and variable, improvements in bundle performance. Opportunities remain to improve adoption of sedation, mechanical ventilation, and early mobility practices.
Collapse
Affiliation(s)
- Michele C. Balas
- University of Nebraska Medical Center College of Nursing, Omaha, Nebraska
| | - Alai Tan
- Center for Research and Health Analytics, College of Nursing, The Ohio State University, Columbus, Ohio
| | - Brenda T. Pun
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, and at the Tennessee Valley Veterans Affairs Geriatric Research Education and Clinical Center, Nashville, Tennessee
| | - Shannon S. Carson
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Lorraine Mion
- Center of Healthy Aging, Self-Management and Complex Care, The Ohio State University College of Nursing
| | | | - Eduard E. Vasilevskis
- Division of General Internal Medicine and Public Health, Section of Hospital Medicine; the Center for Health Services Research; the Center for Quality Aging; and the Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, and a staff physician, Tennessee Valley Veterans Affairs Geriatric Research Education and Clinical Center
| |
Collapse
|
30
|
Wang Y, Lei L, Yang H, He S, Hao J, Liu T, Chen X, Huang Y, Zhou J, Lin Z, Zheng H, Lin X, Huang W, Liu X, Li Y, Huang L, Qiu W, Ru H, Wang D, Wu J, Zheng H, Zuo L, Zeng P, Zhong J, Rong Y, Fan M, Li J, Cai S, Kou Q, Liu E, Lin Z, Cai J, Yang H, Li F, Wang Y, Lin X, Chen W, Gao Y, Huang S, Sang L, Xu Y, Zhang K. Weaning critically ill patients from mechanical ventilation: a protocol from a multicenter retrospective cohort study. J Thorac Dis 2022; 14:199-206. [PMID: 35242382 PMCID: PMC8828530 DOI: 10.21037/jtd-21-1217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 12/15/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Mechanical ventilation (MV) is an important lifesaving method in intensive care unit (ICU). Prolonged MV is associated with ventilator associated pneumonia (VAP) and other complications. However, premature weaning from MV may lead to higher risk of reintubation or mortality. Therefore, timely and safe weaning from MV is important. In addition, identification of the right patient and performing a suitable weaning process is necessary. Although several guidelines about weaning have been reported, compliance with these guidelines is unknown. Therefore, the aim of this study is to explore the variation of weaning in China, associations between initial MV reason and clinical outcomes, and factors associated with weaning strategies using a multicenter cohort. METHODS This multicenter retrospective cohort study will be conducted at 17 adult ICUs in China, that included patients who were admitted in this 17 ICUs between October 2020 and February 2021. Patients under 18 years of age and patients without the possibility for weaning will be excluded. The questionnaire information will be registered by a specific clinician in each center who has been evaluated and qualified to carry out the study. DISCUSSION In a previous observational study of weaning in 17 ICUs in China, weaning practices varies nationally. Therefore, a multicenter retrospective cohort study is necessary to be conducted to explore the present weaning methods used in China. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR) (No. ChiCTR2100044634).
Collapse
Affiliation(s)
- Yingzhi Wang
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Liming Lei
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Huawei Yang
- Guangdong Hospital of Traditional Chinese Medicine, Zhuhai, China
| | | | - Junhai Hao
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Tao Liu
- Guangdong Hospital of Traditional Chinese Medicine, Zhuhai, China
| | | | - Yongbo Huang
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jing Zhou
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhimin Lin
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Haichong Zheng
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaoling Lin
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Weixiang Huang
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaoqing Liu
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yimin Li
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Linxi Huang
- The First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Wenbing Qiu
- The First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Huangyao Ru
- The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Danni Wang
- The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Jianfeng Wu
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huifang Zheng
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liuer Zuo
- Shunde Hospital of Southern Medical University, Foshan, China
| | - Peiling Zeng
- Shunde Hospital of Southern Medical University, Foshan, China
| | - Jian Zhong
- Shunde Hospital Guangzhou University of Chinese Medicine (Shunde District Hospital of Chinese Medicine of Foshan City), Foshan, China
| | - Yanhui Rong
- Shunde Hospital Guangzhou University of Chinese Medicine (Shunde District Hospital of Chinese Medicine of Foshan City), Foshan, China
| | - Min Fan
- The Third Affiliated Hospital of Sun Yat-sen University- Lingnan Hospital, Guangzhou, China
| | - Jianwei Li
- Zhongshan People’s Hospital, Zhongshan, China
| | | | - Qiuye Kou
- Foresea Life Insurance Guangzhou General Hospital, Guangzhou, China
| | - Enhe Liu
- Foresea Life Insurance Guangzhou General Hospital, Guangzhou, China
| | - Zhuandi Lin
- Guangzhou panyu Central Hospital, Guangzhou, China
| | - Jingjing Cai
- Guangzhou panyu Central Hospital, Guangzhou, China
| | - Hong Yang
- The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Fen Li
- The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Yanhong Wang
- The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xinfeng Lin
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Weitao Chen
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Youshan Gao
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shifang Huang
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Ling Sang
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuanda Xu
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Kouxing Zhang
- The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
31
|
Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
32
|
Sepsis and Septic Shock. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00038-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
|
33
|
The AIR-SED Study: A Multicenter Cohort Study of SEDation Practices, Deep Sedation, and Coma Among Mechanically Ventilated AIR Transport Patients. Crit Care Explor 2021; 3:e0597. [PMID: 34909700 PMCID: PMC8663813 DOI: 10.1097/cce.0000000000000597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: To characterize prehospital air medical transport sedation practices and test the hypothesis that modifiable variables related to the monitoring and delivery of analgesia and sedation are associated with prehospital deep sedation. DESIGN: Multicenter, retrospective cohort study. SETTING: A nationwide, multicenter (approximately 130 bases) air medical transport provider. PATIENTS: Consecutive, adult mechanically ventilated air medical transport patients treated in the prehospital environment (January 2015 to December 2020). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as: 1) Richmond Agitation-Sedation Scale of –3 to –5; 2) Ramsay Sedation Scale of 5 or 6; or 3) Glasgow Coma Scale of less than or equal to 9. Coma was defined as being unresponsive and based on median sedation depth: 1) Richmond Agitation-Sedation Scale of –5; 2) Ramsay of 6; or 3) Glasgow Coma Scale of 3. A total of 72,148 patients were studied. Prehospital deep sedation was observed in 63,478 patients (88.0%), and coma occurred in 42,483 patients (58.9%). Deeply sedated patients received neuromuscular blockers more frequently and were less likely to have sedation depth documented with a validated sedation depth scale (i.e., Ramsay or Richmond Agitation-Sedation Scale). After adjusting for covariates, a multivariable logistic regression model demonstrated that the use of longer-acting neuromuscular blockers (i.e., rocuronium and vecuronium) was an independent predictor of deep sedation (adjusted odds ratio, 1.28; 95% CI, 1.22–1.35; p < 0.001), while use of a validated sedation scale was associated with a lower odds of deep sedation (adjusted odds ratio, 0.29; 95% CI, 0.27–0.30; p < 0.001). CONCLUSIONS: Deep sedation (and coma) is very common in mechanically ventilated air transport patients and associated with modifiable variables related to the monitoring and delivery of analgesia and sedation. Sedation practices in the prehospital arena and associated clinical outcomes are in need of further investigation.
Collapse
|
34
|
Malik J. Animal-Assisted Interventions in Intensive Care Delirium: A Literature Review. AACN Adv Crit Care 2021; 32:391-397. [PMID: 34879136 DOI: 10.4037/aacnacc2021708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Critical illness has lasting consequences on the mind and the body. Acute sequelae include a decline in cognitive function known as delirium. Increased interest in improving outcomes for intensive care unit survivors without a high incidence of delirium has initiated a focus on an array of nonpharmacologic interventions in many countries. One such intervention is animalassisted intervention. As the role of animals in human healing is being recognized by clinicians, need is increasing for formal and professionally directed therapies. This review ascertains the effect of interaction with animals on critically ill patients. Emerging evidence indicates that animal-assisted intervention improves the efficacy of critical care regarding primary symptoms and secondary factors of delirium.
Collapse
Affiliation(s)
- Jahanzeb Malik
- Jahanzeb Malik is the Senior Registrar, Emergency and Critical Care, Rawalpindi Institute of Cardiology, Rawal Road, Rawalpindi, 46000, Pakistan
| |
Collapse
|
35
|
Casamento AJ, Serpa Neto A, Young M, Lawrence M, Taplin C, Eastwood GM, Ghosh A, Bellomo R. A Phase II Cluster-Crossover Randomized Trial of Fentanyl versus Morphine for Analgosedation in Mechanically Ventilated Patients. Am J Respir Crit Care Med 2021; 204:1286-1294. [PMID: 34543581 DOI: 10.1164/rccm.202106-1515oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: The continuous infusion of fentanyl or morphine is often prescribed to assist with analgesia and sedation (analgosedation) during mechanical ventilation. Objectives: To compare the effect of fentanyl versus morphine on patient-centered outcomes in ventilated patients. Methods: We conducted a cluster-randomized, cluster-crossover trial between July 2019 and August 2020 in two adult ICUs. We compared two continuous infusion regimens (fentanyl versus morphine). One ICU was randomized to the fentanyl-morphine sequence and the other to the morphine-fentanyl sequence. The primary outcome was the number of ventilator-free days at Day 28. Secondary outcomes included, among others, duration of mechanical ventilation in survivors and ICU-free days at Day 28. Measurements and Main Results: Via cluster allocation, we randomized 737 patients. Of these, 56 were excluded because of the opt-out consent process, leaving 681 (344 to fentanyl and 337 to morphine) for primary analysis (median [interquartile range] age, 59 [44-69] years). Median ventilator-free days at Day 28 were 26.1 (20.7-27.3) in the fentanyl versus 25.3 (19.1-27.2) in the morphine group (median difference, 0.79 [95% confidence interval, 0.31 to 1.28], P = 0.001). ICU-free days were greater (P < 0.001) and length of stay in the ICU for survivors shorter (P < 0.001) in the fentanyl group. All other secondary outcomes were not statistically different by treatment group. Conclusions: Among adult patients requiring mechanical ventilation, compared with morphine, fentanyl infusion significantly increased the median number of ventilator-free days at Day 28. The choice of opioid infusion agent may affect clinical outcomes and requires further investigation.
Collapse
Affiliation(s)
- Andrew J Casamento
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Intensive Care, Northern Hospital, Melbourne, Australia.,Department of Critical Care and
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Critical Care and.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Data Analytics Research and Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; and.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Marcus Young
- Department of Critical Care and.,Data Analytics Research and Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; and
| | - Mervin Lawrence
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Christina Taplin
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Critical Care and
| | - Angajendra Ghosh
- Department of Intensive Care, Northern Hospital, Melbourne, Australia.,Department of Medical Education, University of Melbourne, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Critical Care and.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Data Analytics Research and Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; and
| |
Collapse
|
36
|
Law D, Morgan M. Listening to patients in intensive care. Pract Neurol 2021; 22:96-97. [PMID: 34845099 DOI: 10.1136/practneurol-2021-003255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Daniel Law
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Matthew Morgan
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| |
Collapse
|
37
|
Weinberger J, Cocoros N, Klompas M. Ventilator-Associated Events: Epidemiology, Risk Factors, and Prevention. Infect Dis Clin North Am 2021; 35:871-899. [PMID: 34752224 DOI: 10.1016/j.idc.2021.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The Centers for Disease Control and Prevention shifted the focus of safety surveillance in mechanically ventilated patients from ventilator-associated pneumonia to ventilator-associated events in 2013 to increase the objectivity and reproducibility of surveillance and to encourage quality improvement programs to focus on preventing a broader array of complications. Ventilator-associated events are associated with a doubling of the risk of dying. Prospective studies have found that minimizing sedation, increasing spontaneous awakening and breathing trials, and conservative fluid management can decrease event rates and the duration of ventilation. Multifaceted interventions to enhance these practices can decrease ventilator-associated event rates.
Collapse
Affiliation(s)
- Jeremy Weinberger
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 200 Washington Street, Boston, MA 02111, USA
| | - Noelle Cocoros
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| |
Collapse
|
38
|
Ziaka M, Exadaktylos A. Brain-lung interactions and mechanical ventilation in patients with isolated brain injury. Crit Care 2021; 25:358. [PMID: 34645485 PMCID: PMC8512596 DOI: 10.1186/s13054-021-03778-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/30/2021] [Indexed: 11/29/2022] Open
Abstract
During the last decade, experimental and clinical studies have demonstrated that isolated acute brain injury (ABI) may cause severe dysfunction of peripheral extracranial organs and systems. Of all potential target organs and systems, the lung appears to be the most vulnerable to damage after brain injury (BI). The pathophysiology of these brain–lung interactions are complex and involve neurogenic pulmonary oedema, inflammation, neurodegeneration, neurotransmitters, immune suppression and dysfunction of the autonomic system. The systemic effects of inflammatory mediators in patients with BI create a systemic inflammatory environment that makes extracranial organs vulnerable to secondary procedures that enhance inflammation, such as mechanical ventilation (MV), surgery and infections. Indeed, previous studies have shown that in the presence of a systemic inflammatory environment, specific neurointensive care interventions—such as MV—may significantly contribute to the development of lung injury, regardless of the underlying mechanisms. Although current knowledge supports protective ventilation in patients with BI, it must be born in mind that ABI-related lung injury has distinct mechanisms that involve complex interactions between the brain and lungs. In this context, the role of extracerebral pathophysiology, especially in the lungs, has often been overlooked, as most physicians focus on intracranial injury and cerebral dysfunction. The present review aims to fill this gap by describing the pathophysiology of complications due to lung injuries in patients with a single ABI, and discusses the possible impact of MV in neurocritical care patients with normal lungs.
Collapse
Affiliation(s)
- Mairi Ziaka
- Department of Internal Medicine, Thun General Hospital, Thun, Switzerland.
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
39
|
Implementation and Routinization of the ABCDE Bundle: A Mixed Methods Evaluation. Dimens Crit Care Nurs 2021; 40:333-344. [PMID: 34606224 DOI: 10.1097/dcc.0000000000000495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The ABCDE (Awakening and Breathing Coordination, Delirium monitoring and management, and Early exercise/mobility) bundle has been associated with reductions in delirium incidence and improved patient outcomes but has not been widely adopted. OBJECTIVE The objective of this study was to determine how to facilitate ABCDE bundle adoption by examining the impact of different implementation strategies on bundle adherence rates and assessing clinicians' perceptions of the bundle and implementation efforts. METHODS This study examined the effect of 2 bundle implementation strategies on patient care in 8 adult intensive care units. The basic strategy included electronic health record (EHR) modification, whereas the enhanced strategy included EHR modification plus additional bundle training, clinical champions, and staff engagement. A total of 84 nurses, physicians, and therapists participated in interviews and a survey to assess bundle implementation. RESULTS Respondents indicated bundle use resulted in "best care" through care standardization and coordination and improved patient outcomes. Intensive care units in both intervention groups had significant improvements in bundle adherence after implementation efforts, but intensive care units in the basic intervention group outperformed other sites after initiating their own implementation strategies. Successful implementation tactics included incorporating the bundle into multidisciplinary rounds and providing ongoing support, training, and routine auditing and feedback. DISCUSSION The ABCDE bundle can improve quality of care and outcomes, and implementation can be accelerated through EHR tools, trainings, and performance feedback.
Collapse
|
40
|
Ho K, Bare I, Sy E, Singh J, Opotowsky AR, Dehghani P. Trends in Patient Characteristic, Cost, and Mortality Among Mechanically Ventilated Adult Patients With Congenital Heart Disease in the United States. CJC Open 2021; 4:197-205. [PMID: 35198937 PMCID: PMC8843989 DOI: 10.1016/j.cjco.2021.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/21/2021] [Indexed: 12/20/2022] Open
Abstract
Background There is an increasing number of adults with congenital heart disease (ACHD), but critically ill patients with ACHD remain understudied. The objective of this study was to evaluate patient characteristics and trends in mortality of mechanically ventilated patients with ACHD. Methods We evaluated ACHD with an ICD-9 procedure code for mechanical ventilation using the National Inpatient Sample (NIS), a public all-payer inpatient United States database, from 2005 to 2014. Primary and secondary outcomes were evaluated using multivariable logistic regression. Results There were 10,962 of 77,334,704 discharges, representing 52,876 (0.6%) hospitalizations that were for patients with ACHD who required mechanical ventilation (MV). Mean age was 59 years (interquartile range: 45-71); 45.3% were female patients. The number of patients with ACHD requiring MV increased over the years (2342 to 7775, P < 0.001). Age and comorbidities of this cohort also increased (55 to 59, P < 0.001; 1 to 2, P < 0.001). Case-fatality ratio remained stable over the years (0.254 to 0.259, P = 0.42). Median cost of hospital stay was USD $49,583 and remained stable over the study period (P = 0.42), whereas total cost increased from $115 million to $564 million (P < 0.001). Conclusions The number of mechanically ventilated ACHD has increased over the years. Remarkably, despite an increase in the age and comorbidity burden in this cohort, case-fatality ratio of these patients and the cost per patient remained stable. Nonetheless, there is a growing need for health care resources in the management of this cohort of patients. Further studies will need to be conducted to evaluate the underlying physiological impact and prognosis of MV in specific subsets of ACHD.
Collapse
Affiliation(s)
- Karen Ho
- Division of Internal Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- College of Medicine, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Idris Bare
- Division of Internal Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- College of Medicine, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Eric Sy
- College of Medicine, University of Saskatchewan, Regina, Saskatchewan, Canada
- Department of Critical Care, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Jyoptal Singh
- Department of Cardiology, Prairie Vascular Research Inc, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Alexander R. Opotowsky
- Adult Congenital Heart Disease Program, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Payam Dehghani
- College of Medicine, University of Saskatchewan, Regina, Saskatchewan, Canada
- Department of Cardiology, Prairie Vascular Research Inc, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
- Corresponding author: Dr Payam Dehghani, Department of Cardioneurosciences, Regina General Hospital, 3rd floor,1440 14th Avenue, Regina, Saskatchewan S4P 0W5, Canada. Tel.: +1-306-596-9799.
| |
Collapse
|
41
|
Balit CR, LaRosa JM, Ong JSM, Kudchadkar SR. Sedation protocols in the pediatric intensive care unit: fact or fiction? Transl Pediatr 2021; 10:2814-2824. [PMID: 34765503 PMCID: PMC8578750 DOI: 10.21037/tp-20-328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 03/03/2021] [Indexed: 11/06/2022] Open
Abstract
Comfort of the critically unwell pediatric patient is paramount to ensuring good outcomes. Analgesia-based, multimodal sedative approaches are the foundation for comfort, whereby pain is addressed first and then sedation titrated to a predefined target based on the goals of care. Given the heterogeneity of patients within the pediatric critical care population, the approach must be individualized based on the age and developmental stage of the child, physiologic status, and degree of invasive treatment required. In both the adult and pediatric intensive care unit (PICU), sedation titration is practiced as standard of care to meet therapeutic goals with a focus on facilitating early rehabilitation and extubation while avoiding under- and over-sedation. Sedation protocols have been developed as methods to reduce variability and optimize goal-directed therapy. Components of a sedation protocol include routine analgesia and sedation scoring with validated tools at specified intervals and a predefined algorithm that allows the titration of analgesia and sedation based on those assessments. Sedation protocols are designed to improve communication and documentation of sedation goals while also empowering the bedside team to respond rapidly to changes in a patient's clinical status. Previously it was thought that sedation protocols would consistently reduce duration of mechanical ventilation (MV) and length of stay (LOS) for patients in the PICU, however, this has not been the case. Nonetheless, introduction of sedation protocols has provided several benefits, including: (I) reduction in benzodiazepine usage; (II) improvements in interprofessional communication surrounding sedation goals and management of sedation goals; and (III) reductions in iatrogenic withdrawal symptoms. Successful implementation of sedation protocols requires passionate clinical champions and a robust implementation, education, and sustainability plan. Emerging evidence suggests that sedation protocols as part of a bundle of quality improvement initiatives will form the basis of future studies to improve short- and long-term outcomes after PICU discharge. In this review, we aim to define sedation protocols in the context of pediatric critical care and highlight important considerations for clinical practice and research.
Collapse
Affiliation(s)
- Corrine R Balit
- Paediatric Intensive Care Unit, John Hunter Hospital, Newcastle, Australia
| | - Jessica M LaRosa
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jacqueline S M Ong
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
42
|
Meiser A, Volk T, Wallenborn J, Guenther U, Becher T, Bracht H, Schwarzkopf K, Knafelj R, Faltlhauser A, Thal SC, Soukup J, Kellner P, Drüner M, Vogelsang H, Bellgardt M, Sackey P. Inhaled isoflurane via the anaesthetic conserving device versus propofol for sedation of invasively ventilated patients in intensive care units in Germany and Slovenia: an open-label, phase 3, randomised controlled, non-inferiority trial. THE LANCET RESPIRATORY MEDICINE 2021; 9:1231-1240. [PMID: 34454654 DOI: 10.1016/s2213-2600(21)00323-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/27/2021] [Accepted: 06/29/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies indicate that isoflurane could be useful for the sedation of patients in the intensive care unit (ICU), but prospective studies evaluating isoflurane's efficacy have been small. The aim of this study was to test whether the sedation with isoflurane was non-inferior to sedation with propofol. METHODS This phase 3, randomised, controlled, open-label non-inferiority trial evaluated the efficacy and safety of up to 54 h of isoflurane compared with propofol in adults (aged ≥18 years) who were invasively ventilated in ICUs in Germany (21 sites) and Slovenia (three sites). Patients were randomly assigned (1:1) to isoflurane inhalation via the Sedaconda anaesthetic conserving device (ACD; Sedana Medical AB, Danderyd, Sweden; ACD-L [dead space 100 mL] or ACD-S [dead space 50 mL]) or intravenous propofol infusion (20 mg/mL) for 48 h (range 42-54) using permuted block randomisation with a centralised electronic randomisation system. The primary endpoint was percentage of time in Richmond Agitation-Sedation Scale (RASS) range -1 to -4, assessed in eligible participants with at least 12 h sedation (the per-protocol population), five or more RASS measurements, and no major protocol violations, with a non-inferiority margin of 15%. Key secondary endpoints were opioid requirements, spontaneous breathing, time to wake-up and extubation, and adverse events. Safety was assessed in all patients who received at least one dose. The trial is complete and registered with EudraCT, 2016-004551-67. FINDINGS Between July 2, 2017, and Jan 12, 2020, 338 patients were enrolled and 301 (89%) were randomly assigned to isoflurane (n=150) or propofol (n=151). 146 patients (97%) in each group completed the 24-h follow-up. 146 (97%) patients in the isoflurane group and 148 (98%) of patients in the propofol group were included in the per-protocol analysis of the primary endpoint. Least-squares mean percentage of time in RASS target range was 90·7% (95% CI 86·8-94·6) for isoflurane and 91·1% (87·2-95·1) for propofol. With isoflurane sedation, opioid dose intensity was 29% lower than with propofol for the overall sedation period (0·22 [0·12-0·34] vs 0·32 [0·21-0·42] mg/kg per h morphine equivalent dose, p=0·0036) and spontaneous breathing was more frequent on day 1 (odds ratio [OR] 1·72 [1·12-2·64], generalised mixed linear model p=0·013, with estimated rates of 50% of observations with isoflurane vs 37% with propofol). Extubation times were short and median wake-up was significantly faster after isoflurane on day 2 (20 min [IQR 10-30] vs 30 min [11-120]; Cox regression p=0·0011). The most common adverse events by treatment group (isoflurane vs propofol) were: hypertension (ten [7%] of 150 vs two [1%] of 151), delirium (eight [5%] vs seven [5%]), oliguria (seven [5%] vs six [4%]), and atrial fibrillation (five [3%] vs four [3%]). INTERPRETATION These results support the use of isoflurane in invasively ventilated patients who have a clinical need for sedation. FUNDING Sedana Medical AB.
Collapse
Affiliation(s)
- Andreas Meiser
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany.
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Jan Wallenborn
- Department of Anesthesiology and Intensive Care Medicine, Helios Klinikum Aue, Aue, Germany
| | - Ulf Guenther
- University Clinic of Anaesthesiology, Intensive Care, Emergency Medicine, Pain Therapy, Klinikum Oldenburg, Oldenburg, Germany
| | - Tobias Becher
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Hendrik Bracht
- Department of Emergency Medicine, and Department of Anesthesiology and Intensive Care, University Hospital Ulm, Ulm, Germany
| | - Konrad Schwarzkopf
- Department of Anesthesia and Intensive Care, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Rihard Knafelj
- University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - Serge C Thal
- Helios University Hospital Wuppertal, University of Witten-Herdecke, Department of Anesthesiology, Wuppertal, Germany; University Medical Center of the Johannes Gutenberg-University Mainz, Department of Anesthesiology, Mainz, Germany
| | - Jens Soukup
- Department of Anaesthesiology, Intensive Care Medicine and Palliative Care Medicine, Carl-Thiem-Hospital, Cottbus, Germany
| | - Patrick Kellner
- Department of Anesthesiology and Intensive Care, University of Lübeck, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Matthias Drüner
- Department of Anaesthesiology and Intensive Care Medicine, Emden Hospital, Emden, Germany
| | - Heike Vogelsang
- St Josef-Hospital Bochum, Department of Anaesthesiology and Intensive Care Medicine, University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | - Martin Bellgardt
- St Josef-Hospital Bochum, Department of Anaesthesiology and Intensive Care Medicine, University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | - Peter Sackey
- Department of Physiology and Pharmacology, Unit of Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | | |
Collapse
|
43
|
Purivatra E, Guenette M, Coleman B, Cheung A, Burry L. High-versus low-dose clonidine for sedation and analgesia in critically ill adults: A retrospective cohort study. J Clin Pharm Ther 2021; 46:1706-1713. [PMID: 34448218 DOI: 10.1111/jcpt.13523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 12/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Limited data suggest clonidine may be useful for sedation and analgesia in critically ill patients. Our objectives were to describe clonidine dosing regimens used for sedation and analgesia in critically ill adults, the associated adverse effects (i.e., hypotension), and whether clonidine dose was associated with dosage reductions of traditional sedatives and analgesics. METHODS We conducted a retrospective cohort study of all critically ill adults who received enteral clonidine for sedation and analgesia during a five-year study period (2011-2016). We categorized patients as low-dose (LD ≤0.4 mg/day) or high-dose (HD >0.4 mg/day) based on the maximum total daily clonidine dose. RESULTS AND DISCUSSION In total, 166 patients received clonidine for sedation analgesia; the median age was 56 years, 36% were female, and 96% were mechanically ventilated (median 10 days). Eighty-eight patients (53%) received HD clonidine. There were no significant differences in hypotension, bradycardia, rebound hypertension or tachycardia between groups. The HD group had a greater reduction in mean daily opioid requirements throughout clonidine use compared with the LD group (-218.8 mcg vs. -42.5 mcg fentanyl equivalents, p = 0.049), while antipsychotic doses increased (5.7 mg vs. 0 mg olanzapine equivalents, p = 0.04) and sedative doses did not differ. WHAT IS NEW AND CONCLUSIONS Clonidine doses >0.4 mg/day were associated with a decrease in patients' opioid but not sedative requirements without causing significant adverse effects. Antipsychotic doses increased in conjunction with HD clonidine use.
Collapse
Affiliation(s)
| | | | - Brenda Coleman
- Infectious Disease Epidemiology Research Unit, Mount Sinai Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Alexandra Cheung
- Department of Pharmacy, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Lisa Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto Mount Sinai Hospital, Toronto, Ontario, Canada
| |
Collapse
|
44
|
Impact of a Real-Time, Pharmacist-Led, Intensive Care Unit-Based Feedback Intervention on Analgesia and Sedation Quality Among Mechanically Ventilated Patients. J Nurs Care Qual 2021; 36:242-248. [PMID: 33259465 DOI: 10.1097/ncq.0000000000000527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Consensus guidelines for pain, agitation, and delirium (PAD) in mechanically ventilated patients recommend maintaining a light level of sedation. LOCAL PROBLEM Consistent attainment of target PAD assessments in mechanically ventilated ICU patients is often challenging. METHODS This is a single-center, prospective study. INTERVENTIONS In the intervention group, a pharmacist provided weekly feedback to nurses on their success in achieving target PAD assessments compared with a historical cohort without feedback. RESULTS Overall, 478 patients and 205 nurses were included. The odds of having weekly Richmond Agitation-Sedation Scale (RASS) score, pain score goals, and Confusion Assessment Method for the ICU (CAM-ICU) negative assessments at goal between the intervention and control groups fluctuated over time without a discernible trend. CONCLUSION The provision of weekly feedback to nurses on PAD nursing assessments by a pharmacist did not impact the achievement of PAD goals among critically ill mechanically ventilated patients.
Collapse
|
45
|
A One-Day Prospective National Observational Study on Sedation-Analgesia of Patients with Brain Injury in French Intensive Care Units: The SEDA-BIP-ICU (Sedation-Analgesia in Brain Injury Patient in ICU) Study. Neurocrit Care 2021; 36:266-278. [PMID: 34331208 DOI: 10.1007/s12028-021-01298-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/10/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Sedation/analgesia is a daily challenge faced by intensivists managing patients with brain injury (BI) in intensive care units (ICUs). The optimization of sedation in patients with BI presents particular challenges. A choice must be made between the potential benefit of a rapid clinical evaluation and the potential exacerbation of intracranial hypertension in patients with impaired cerebral compliance. In the ICU, a pragmatic approach to the use of sedation/analgesia, including the optimal titration, management of multiple drugs, and use of any type of brain monitor, is needed. Our research question was as follows: the aim of the study is to identify what is the current daily practice regarding sedation/analgesia in the management of patients with BI in the ICU in France? METHODS This study was composed of two parts. The first part was a descriptive survey of sedation practices and characteristics in 30 French ICUs and 27 academic hospitals specializing in care for patients with BI. This first step validates ICU participation in data collection regarding sedation-analgesia practices. The second part was a 1-day prospective cross-sectional snapshot of all characteristics and prescriptions of patients with BI. RESULTS On the study day, among the 246 patients with BI, 106 (43%) had a brain monitoring device and 74 patients (30%) were sedated. Thirty-nine of the sedated patients (53%) suffered from intracranial hypertension, 14 patients (19%) suffered from agitation and delirium, and 7 patients (9%) were sedated because of respiratory failure. Fourteen patients (19%) no longer had a formal indication for sedation. In 60% of the sedated patients, the sedatives were titrated by nurses based on sedation scales. The Richmond Agitation Sedation Scale was used in 80% of the patients, and the Behavioral Pain Scale was used in 92%. The common sedatives and opioids used were midazolam (58.1%), propofol (40.5%), and sufentanil (67.5%). The cerebral monitoring devices available in the participating ICUs were transcranial Doppler ultrasound (100%), intracranial and intraventricular pressure monitoring (93.3%), and brain tissue oxygenation (60%). Cerebral monitoring by one or more monitoring devices was performed in 62% of the sedated patients. This proportion increased to 74% in the subgroup of patients with intracranial hypertension, with multimodal cerebral monitoring in 43.6%. The doses of midazolam and sufentanil were lower in sedated patients managed based on a sedation/analgesia scale. CONCLUSIONS Midazolam and sufentanil are frequently used, often in combination, in French ICUs instead of alternative drugs. In our study, cerebral monitoring was performed in more than 60% of the sedated patients, although that proportion is still insufficient. Future efforts should stress the use of multiple monitoring modes and adherence to the indications for sedation to improve care of patients with BI. Our study suggests that the use of sedation and analgesia scales by nurses involved in the management of patients with BI could decrease the dosages of midazolam and sufentanil administered. Updated guidelines are needed for the management of sedation/analgesia in patients with BI.
Collapse
|
46
|
Abstract
OBJECTIVE To evaluate the impact of bundle interventions on ICU delirium prevalence, duration, and other patients' adverse outcomes. DATA SOURCES The Cochrane Library, PubMed, CINAHL, EMBASE, PsychINFO, and MEDLINE from January 2000 to July 2020. The protocol of the study was registered in International prospective register of systematic reviews (CRD42020163147). STUDY SELECTION Randomized clinical trials or cohort studies that examined the following outcomes were included in the current study: ICU delirium prevalence and duration, proportion of patient-days with coma, ventilator-free days, mechanical ventilation days, ICU or hospital length of stay, and ICU or inhospital or 28-day mortality. DATA EXTRACTION Using a standardized data-collection form, two authors screened the studies and extracted the data independently, and assessed the studies' quality using the Modified Jadad Score Scale for randomized clinical trials and the Newcastle-Ottawa Scale for cohort studies. DATA SYNTHESIS Eleven studies with a total of 26,384 adult participants were included in the meta-analysis. Five studies (three randomized clinical trials and two cohort studies) involving 18,638 patients demonstrated that ICU delirium prevalence was not reduced (risk ratio = 0.92; 95% CI, 0.68-1.24). Meta-analysis showed that the use of bundle interventions was not associated with shortening the duration of ICU delirium (mean difference = -1.42 d; 95% CI, -3.06 to 0.22; two randomized clinical trials and one cohort study), increasing ventilator-free days (mean difference = 1.56 d; 95% CI, -1.56 to 4.68; three randomized clinical trials), decreasing mechanical ventilation days (mean difference = -0.83 d; 95% CI, -1.80 to 0.14; four randomized clinical trials and two cohort studies), ICU length of stay (mean difference = -1.08 d; 95% CI, -2.16 to 0.00; seven randomized clinical trials and two cohort studies), and inhospital mortality (risk ratio = 0.86; 95% CI, 0.70-1.06; five randomized clinical trials and four cohort studies). However, bundle interventions are effective in reducing the proportion of patient-days experiencing coma (risk ratio = 0.47; 95% CI, 0.39-0.57; two cohort studies), hospital length of stay (mean difference = -1.47 d; 95% CI, -2.80 to -0.15; four randomized clinical trials and one cohort study), and 28-day mortality by 18% (risk ratio = 0.82; 95% CI, 0.69-0.99; three randomized clinical trials). CONCLUSIONS This meta-analysis fails to support that bundle interventions are effective in reducing ICU delirium prevalence and duration, but supports that bundle interventions are effective in reducing the proportion of patient-days with coma, hospital length of stay, and 28-day mortality. Larger randomized clinical trials are needed to evaluate the impact of bundle interventions on ICU delirium and other clinical outcomes.
Collapse
|
47
|
Devlin JW, Seth B, Train S, Needham DM. Maintaining light sedation is important: next steps for research. Thorax 2021; 76:1069-1070. [PMID: 34272337 DOI: 10.1136/thoraxjnl-2021-217337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 12/26/2022]
Affiliation(s)
- John W Devlin
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA .,School of Pharmacy, Northeastern University, Boston, Massachusetts, USA
| | - Bhavna Seth
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sarah Train
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
48
|
|
49
|
Sneyers B, Duceppe MA, Frenette AJ, Burry LD, Rico P, Lavoie A, Gélinas C, Mehta S, Dagenais M, Williamson DR, Perreault MM. Strategies for the Prevention and Treatment of Iatrogenic Withdrawal from Opioids and Benzodiazepines in Critically Ill Neonates, Children and Adults: A Systematic Review of Clinical Studies. Drugs 2021; 80:1211-1233. [PMID: 32592134 PMCID: PMC7317263 DOI: 10.1007/s40265-020-01338-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Critically ill patients are at high risk of iatrogenic withdrawal syndrome (IWS), due to exposure to high doses or prolonged periods of opioids and benzodiazepines. PURPOSE To examine pharmacological management strategies designed to prevent and/or treat IWS from opioids and/or benzodiazepines in critically ill neonates, children and adults. METHODS We included non-randomised studies of interventions (NRSI) and randomised controlled trials (RCTs), reporting on interventions to prevent or manage IWS in critically ill neonatal, paediatric and adult patients. Database searching included: PubMed, CINAHL, Embase, Cochrane databases, TRIP, CMA Infobase and NICE evidence. Additional grey literature was examined. Study selection and data extraction were performed in duplicate. Data collected included: population, definition of opioid, benzodiazepine or mixed IWS, its assessment and management (drug or strategy, route of administration, dosage and titration), previous drug exposures and outcomes measures. Methodological quality assessment was performed by two independent reviewers using the Cochrane risk of bias tool for RCTs and the ROBINS-I tool for NRSI. A qualitative synthesis of the results is provided. For the subset of studies evaluating multifaceted protocolised care, we meta-analysed results for 4 outcomes and examined the quality of evidence using GRADE post hoc. RESULTS Thirteen studies were eligible, including 10 NRSI and 3 RCTs; 11 of these included neonatal and paediatric patients exclusively. Eight studies evaluated multifaceted protocolised interventions, while 5 evaluated individual components of IWS management (e.g. clonidine or methadone at varying dosages, routes of administration and duration of tapering). IWS was measured using an appropriate tool in 6 studies. Ten studies reported upon occurrence of IWS, showing significant reductions (n = 4) or no differences (n = 6). Interventions failed to impact duration of mechanical ventilation, ICU length of stay, and adverse effects. Impact on opioid and/or benzodiazepine total doses and duration showed no differences in 4 studies, while 3 showed opioid and benzodiazepine cumulative doses were significantly reduced by 20-35% and 32-66%, and treatment durations by 1.5-11 and 19 days, respectively. Variable effects on intervention drug exposures were found. Weaning durations were reduced by 6-12 days (n = 4) for opioids and/or methadone and by 13 days (n = 1) for benzodiazepines. In contrast, two studies using interventions centred on transition to enteral routes or longer tapering durations found significant increases in intervention drug exposures. Interventions had overall non-significant effects on additional drug requirements (except for one study). Included studies were at high risk of bias, relating to selection, detection and reporting bias. CONCLUSION Interventions for IWS management fail to impact duration of mechanical ventilation or ICU length of stay, while effect on occurrence of IWS and drug exposures is inconsistent. Heterogeneity in the interventions used and methodological issues, including inappropriate and/or subjective identification of IWS and bias due to study design, limited the conclusions.
Collapse
Affiliation(s)
- Barbara Sneyers
- Pharmacy Department, Centre Hospitalier Universitaire UCL Namur, Yvoir, Belgium.
| | | | - Anne Julie Frenette
- Faculté de Pharmacie, Université de Montréal, Montreal, Canada.,Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
| | - Lisa D Burry
- Pharmacy Department, Mount Sinai Hospital, Sinai Health System, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Philippe Rico
- Faculté de Médicine, Université de Montréal, Montreal, Canada.,Department of Critical Care, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
| | - Annie Lavoie
- Pharmacy Department, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montreal, Canada.,Centre for Nursing Research/Lady Davis Institute, Jewish General Hospital, Montreal, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Maryse Dagenais
- Paediatric Intensive Care Unit, McGill University Health Centre, Montreal, Canada
| | - David R Williamson
- Faculté de Pharmacie, Université de Montréal, Montreal, Canada.,Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
| | - Marc M Perreault
- Pharmacy Department, McGill University Health Centre, Montreal, Canada.,Faculté de Pharmacie, Université de Montréal, Montreal, Canada
| |
Collapse
|
50
|
Via-Clavero G, Frade-Mera MJ, Alonso-Crespo D, Castanera-Duro A, Gil-Castillejos D, Vallés-Fructuoso O, Rodríguez-Mondéjar JJ, López-López C, Robleda G, Acevedo-Nuevo M. Future lines of research on pain care, sedation, restraints and delirium in the critically ill patient. ENFERMERIA INTENSIVA 2021; 32:57-61. [PMID: 34099265 DOI: 10.1016/j.enfie.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/14/2021] [Indexed: 11/26/2022]
Affiliation(s)
- G Via-Clavero
- Enfermera Clínica, Área del Paciente Crítico, Hospital Universitari de Bellvitge, Profesora Asociada, Escuela de Enfermería, Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Grup de Recerca Infermera (GRIN-IDIBELL), Spain.
| | - M J Frade-Mera
- Enfermera Clínica, Área del Paciente Crítico, Hospital Universitario 12 de Octubre, Profesora Asociada, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, Spain
| | - D Alonso-Crespo
- Enfermero, Unidad de Cuidados Intensivos, Área Sanitaria de Vigo, Hospital Álvaro Cunqueiro SERGAS-UVigo, Translational Neuroscience Group-CIBERSAM, Galicia Sur, Instituto de Investigación Sanitaria (IIS Galicia Sur), Spain
| | - A Castanera-Duro
- Enfermero Clínico, Área del paciente crítico, Hospital Universitario de Girona Dr. Josep Trueta, Profesor Asociado departamento de Enfermería Universitat de Girona (UdG), Spain
| | - D Gil-Castillejos
- Enfermera Clínica, Área de Críticos, Servicio de Medicina Intensiva, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - O Vallés-Fructuoso
- Enfermera, Unidad de Cuidados Intensivos, Hospital Vall d'Hebrón, Barcelona, Spain
| | - J J Rodríguez-Mondéjar
- Enfermero en UME-2 Alcantarilla, Gerencia de Urgencias y Emergencias Sanitarias 061 Región de Murcia, Servicio Murciano de Salud, Profesor asociado en la Facultad de Enfermería de la Universidad de Murcia, Campus Mare Nostrum, Miembro del grupo de investigación ENFERAVAN en el IMIB-Arrixaca, Spain
| | - C López-López
- Enfermera, Departamento de Cuidados Intensivos, Hospital Universitario 12 de Octubre, Madrid, Investigadora, Grupo de Investigación en Cuidados (InveCuid), Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Profesora Asociada, Facultad de Enfermería Fisioterapia y Podología, Universidad Complutense de Madrid, Spain
| | - G Robleda
- Campus docente Fundación Privada Sant Joan de Déu, Escuela de Enfermería, Universidad de Barcelona, Centro Cochrane Iberoamericano, Spain
| | - M Acevedo-Nuevo
- Enfermera, Organización Nacional de Trasplantes, Grupo de Investigación en Enfermería y Cuidados de Salud - Instituto de Investigación Sanitaria Puerta de Hierro - Segovia de Arana (IDIPHISA), Spain
| | | |
Collapse
|